Basics Arthroplasty Shrinand

Basics in
HIP AND KNEE

ARTHROPLASTY
Editor
Shrinand V. Vaidya MS, FACS (USA)
Professor Of Orthopaedic Surgery
King Edward VII Memorial Hospital
Mumbai, India
Key Contributors
Thomas P. Sculco MD
Douglas A. Dennis MD
Javad Parvizi MD
Foreword By
Thomas P. Sculco MD
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Basics in Hip and Knee Arthroplasty, 1e, Shrinand V. Vaidya
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FOREWORD
Total joint arthroplasty is truly one of the great surgical advances of

the twentieth century. It has led to relief of pain and improved mobil-
ity in countless sufferers of arthritis throughout the world. The surgical
techniques and improvements in implant design have led to outstanding
outcomes in the vast majority of patients undergoing these procedures.
In many hospital centers throughout the world, joint replacement surgery
has become a common procedure, and protocols and clinical pathways
continue to evolve in the management of these patients undergoing joint
replacement. Dr. Shrinand Vaidya has provided a comprehensive text with
an international roster of experts in joint replacement to cover the basic
and more complex techniques in proper surgical and perioperative man-
agement of patients undergoing joint replacement.The chapters are beauti-
fully illustrated and accompanying videos help to instruct the reader in the
latest in surgical techniques.
The authors have provided a step wise approach to both total hip and
knee arthroplasty, beginning with preoperative planning to the postopera-
tive management. The expert quality of the authors gives the reader the
most evidence based and experienced surgeons’ recommendation for the
approach to the arthritic patient undergoing joint replacement. The chap-
ters are comprehensive, clearly written and provide both the experienced
and beginning arthroplasty surgeon with outstanding advice in preparing
for and executing a well done arthroplasty. This text will instruct neophytes
but also help refresh those who do joint replacement less commonly in
their practice. Ways to prevent infection and manage blood replacement are
also addressed in the text.
The international expert authors also provide a broad spectrum of
experience in such topics as unicompartmental knee replacement, the
high flex designs and cemented and cement-less implants, how to select
the proper patient for their use and achieve excellent outcomes. The book
emphasizes the surgical techniques needed to achieve outstanding results
and this is key to our patients that the procedure be well-performed and
complications avoided.
I congratulate Dr. Vaidya on a superb accomplishment in provid-
ing a much needed and comprehensive book. It deals with the basics in
implant technique and planning in both the hip and knee (often these are
vii
fragmented and not available in a single text). This book will become a
reference text that is not on the shelf but on the desk of every surgeon that
cares for and operates on the arthritic patient treated with joint replace-
ment. It will be reviewed regularly and provide great assistance to all doing
joint replacement and will lead to significant improvement in our surgical
outcomes.
Thomas P. Sculco MD
Surgeon-in-Chief, Emeritus
Hospital for Special Surgery
New York, N.Y., USA
PREFACE
The demand for hip and knee replacement surgery is

ever increasing, especially in Asia. The challenges are
enormous as most of the presentations are delayed
because of lack of awareness. Although lot has been
done by collaborative efforts of arthroplasty societies,
in liaison with companies, there are many finer aspects
that brochures and workshops won’t be able to explain.
Also, not everyone is fortunate enough to be fellowship
trained under the able guidance of a stalwart.
This book is intended to be the extension of “scribbled notes” of a
fellow, after a robust hip and knee adult reconstruction fellowship pro-
gramme at the end of the year. It rather concentrates on planning and
executional aspects, of choosing a right implant, keeping key instruments
on the trolley and tips and pearls to avoid major mishaps for beginners.
Our intention is to facilitate beginners to read it the “night before” and
get essence of do’s and don’t.
We are fortunate to have Thomas Sculco, Director and Chief Surgeon,
Hospital for Special Surgery, Cornell University, New York as a contribu-
tor who is kind enough to have consented for the Foreword for this book.
His contribution on Planning and Selection of Implant will immensely
help budding arthroplasty surgeons to plan their surgeries. Javad Parvizi,
Vice-Chair at Rothman’s Orthopaedics, Thomas Jefferson University,
Philadelphia has a major contribution towards infection prevention proto-
col, and is kind enough to consent to contribute synopsis of his “consen-
sus” meeting held in 2013. This chapter will go long way in preventing
prosthetic joint infection, which otherwise can play havoc with patients
and healthcare providers alike. Douglas Dennis, Assistant Clinical Professor,
Dept. of Orthopaedics, University of Colorado School of Medicine is kind
enough to contribute major chapters pertaining to TKA. Doug’s chapters
with vivid photographs, of step-by-step cementing in TKA, patellar resur-
facing, have potential to refine every reader to a level of finesse, like the
Master himself!
Many stalwarts who founded “Indian Society of Hip and Knee
Surgeons” have let their life-time secrets out and, but for their contribu-
tion, this book was unthinkable. Friends, I hope this book will be handy
ix
for all the budding and occasional hip and knee replacement surgeons. It is
specifically designed for upcoming arthroplasty surgeons, and hence avoids
debates, review of literature, etc. It rather concentrates on practical tips,
quick decision making flow charts, and plan to execute your operation bet-
ter. Experts in their respective fields have contributed, and I hope the end
product will be on every beginner’s desk. A unique and practical chapter
is added at the end, “My Trolley”, which I am sure will be of great help
to team members. It contains illustrations of key instruments; when used,
can make surgical task look simpler, and minus stress. I hope our younger
colleagues would find this book useful in helping them to make the art of
hip and knee arthroplasty an enjoyable experience.
ACKNOWLEDGEMENT
All the founders of Indian Society of Hip & Knee Surgeons (ISHKS), who
have been pillars of strength.
All the Faculty Members and Residents of Department of Orthopaedics,

King Edward VII Memorial Hospital, Mumbai, India, especially Kaushik
Dash and Chintan Patel, who have lion’s share in making this book possible.
Everyone at Elsevier, who put up with me so patiently...
Shrinand V. Vaidya MS, FACS (USA)

Professor of Orthopaedic Surgery & Chief of the Unit
Joint Replacement Surgery
King Edward VII Memorial Hospital
Mumbai, India
Past President, Indian Society of Hip & Knee Surgeons
E-mail: drsvv1@yahoo.com
x
CONTENTS
Foreword vii
Preface ix
Contributors xi
Part 1 Planning of the Hip and Knee Arthroplasty

1. Total Joint Arthroplasty: Medical Parameters 3
Mohan Desai, MS
2. Blood Transfusion Reduction in Total Joint Arthroplasty 15
Javad Parvizi, MD, FRCS
3. Role of Drains in Primary Total Joint Arthroplasty 29
4. Prevention of Periprosthetic Joint Infection 37
5. Pain Management in Arthroplasty 59
Shubhranshu Mohanty, MS, FRCS, FICS, FACS
Part 2 Total Hip Arthroplasty: Techniques and Pearls

6. Radiological Planning of Total Hip Arthroplasty 75
Radiological Planning in Total Hip Arthroplasty 77
Thomas P. Sculco, MD
7. Choosing Implant for Total Hip Arthroplasty 87
8. Tips and Pearls in Total Hip Arthroplasty 100
Tips and Pearls in Total Hip Arthroplasty 101
9. The Cemented Hip: How to Get it Right 118
Atul Panghate, MS
10. Uncemented Total Hip Arthroplasty 138
Vijay C. Bose, MS
11. Total Hip Arthroplasty in Peritrochanteric Fractures 149
CJ Thakkar, MS
12. Fused Hips in Ankylosing Spondylitis 156
Pradeep Bhosle, MS
xviii
13. Total Hip Arthroplasty in Protrusio Acetabulae 174
Javahir Pachore, MCh Orth
Part 3 Total Knee Arthroplasty: Techniques and Pearls

14. Radiological Planning in Primary Total Knee Arthroplasty 183
Mohan Desai, MS
15. Selection of the Implant in Total Knee Arthroplasty 190
HP Bhalodiya, MS
16. Tips and Pearls: Tourniquets and Position in
Total Knee Arthroplasty 204
Shrinand V. Vaidya, MS, FACS
17. Tips and Pearls: Exposure and Retractors in
Total Knee Arthroplasty 211
Total Knee Arthroplasty in Stiff Knee 217
18. Tips and Pearls: Saw Technique in Total Knee
Arthroplasty 222
19. Principles: Alignment and Balancing 230
Hemant Wakankar, MS, DNB, FRCS, MCh Orth, FRCS Orth
20. Cementation Techniques in Total Knee Arthroplasty 240
Cementing in Total Knee Arthroplasty 242
Douglas A. Dennis, MD
21. Patellar Resurfacing in Total Knee Arthroplasty 249
Patellar Resurfacing in Total Knee Arthroplasty 251
22. Unicondylar Knee Arthroplasty 257
Ashok Rajgopal, MS, MCh, FRCS
23. Technique: Fixed Bearing Total Knee Arthroplasty 269
Hemant Wakankar, MS, DNB, FRCS, MCh Orth, FRCS Orth
24. Mobile-Bearing Total Knee Arthroplasty: Technique
and Clinical Results 280
Rotating Platform Total Knee Arthroplasty 282
xviii
25. Management of Tibial Bone Defects 287
Rajesh N. Maniar, MS, M Ch
26. Total Knee Arthroplasty in Fixed Flexion Deformity 302
SKS Marya, MS, DNB, MCh, FRCS, FICS
27. Total Knee Arthroplasty in Stiff Knee 308
Ashok Rajgopal, MS, MCh, FRCS
28. Total Knee Arthroplasty in Post High Tibial Osteotomy 315
Vikram Shah, MS
Part 4 Recent Advances in the Hip and Knee Arthroplasty

29. Trabecular Metal 327
Pichai Suryanarayan, MS
30. Recent Advances in Short Stem Designs 341
SKS Marya, MS, MCh Ortho
31. Hi-Flex Knee Design 350
HP Bhalodiya, MS
Part 5 How do I Plan My Trolley: Special Instruments

32. My Trolley for Total Hip Arthroplasty 367
Javahir Pachore, MCh Ortho
33. My Trolley for Total Knee Arthroplasty 384
Vikram I. Shah, MS
Index 395
xix
PART 1
Planning of the Hip and

Knee Arthroplasty
Chapters
1. Total Joint Arthroplasty: Medical Parameters 3
2. Blood Transfusion Reduction in Total Joint Arthroplasty 15
3. Role of Drains in Primary Total Joint Arthroplasty 29
4. Prevention of Periprosthetic Joint Infection 37
5. Pain Management in Arthroplasty 59
CHAPTER 1
Total Joint Arthroplasty:

Medical Parameters
Mohan Desai, Kumar Kaushik Dash
Nearly 90% of total deaths occurring within 60 days after total hip arthro-
plasty (THA) result from medical complications such as ischaemic heart
disease and thromboembolism.1 The four major medical complications
associated with poor outcomes are cardiopulmonary problems, thrombo-
embolism, infection and delirium. With improved life expectancy and gen-
eral health care system, more and more elderly patients will undergo total
joint arthroplasties. Their age and pre-existing comorbid conditions will
pose a difficult challenge during and after surgery. It is crucial, therefore, for
the young surgeons to understand the role of a multidisciplinary approach
and optimal care in fighting that battle.
This chapter aims at introducing a beginner in arthroplasty to the com-
mon medical problems and dilemmas faced by a surgeon in the periopera-
tive period. We will try to address common questions, and evoke an interest
in the reader to further read clinical evidence on such questions.
WHAT SHOULD I DO ABOUT CARDIOVASCULAR AND

PULMONARY COMPLICATIONS?
Prevention remains the best way to avoid dire consequences of cardiovascular
complications in arthroplasty surgeries. There have been multiple strategies
to anticipate the risk based on preoperative clinical predictors and age of
the patient. As per the American College of Cardiology/American Heart
Association (ACC/AHA) guidelines, the patient is stratified into major, inter-
mediate or minor risk. Surgery is postponed for patient with high-risk clinical
predictors. In patients with low risk, surgery can be done without any delay.
For patients with intermediate risk clinical predictors, functional status is evalu-
ated. When functional capacity exceeds four metabolic equivalents (>4 METs),
the patient is allowed to proceed with the surgery. The functional capacity of
the patient is expressed in terms of METs. One MET is the resting energy
expenditure, i.e., the amount of oxygen consumed by a person when he is
4 Part 1 | Planning of the Hip and Knee Arthroplasty
at rest. It is approximately 3.5 mL of oxygen per kg per minute. Functional

capacity is poor when the amount of oxygen consumed is less than 4 METs.
As far as detection of perioperative myocardial events is concerned,
it is crucial to remember that the patient may develop silent ischaemic
events without any symptoms. Hence, in addition to keeping an eye out
for clinical symptoms, the surgeon should also monitor the patient by serial
ECGs, cardiac-specific biomarkers, comparative echocardiography and/or
nuclear studies.1 Perioperative myocardial infarction (MI) can occur either
from acute thrombotic occlusion or demand ischaemia (more likely). Early
intervention is crucial, and the result of primary angioplasty is better than
thrombolysis in postoperative ST elevation MI. In addition to infarction
and hypoxaemia, intraoperative fluid overload can result in heart failure.
Pulmonary oedema is common around second postoperative day due to
fluid redistribution from extravascular to intravascular space. At any rate,
the surgeon should be vigilant towards the development of cardiovascular
complications such as myocardial ischaemia, arrhythmia and congestive
heart failure; and urgent consultation with a cardiologist should be sought.
Pneumonia, chronic obstructive pulmonary disease (COPD) exacer-
bation, bronchospasm, atelectasis and respiratory failure are the described
postoperative pulmonary complications that cause significant morbidity
and mortality after total joint arthroplasties. Fortunately, these are relatively
uncommon because the surgical sites are not in the vicinity of diaphragm
(the single most risk factor for development of pulmonary complications).
There are certain modifiable risk factors, including surgeries lasting longer
than 3 h, general anaesthesia instead of spinal anaesthesia, current tobacco
use and use of intraoperative pancuronium.These risk factors should be tar-
geted when attempting to prevent postoperative complications. Age more
than 70, COPD and obstructive sleep apnea are amongst the nonmodifi-
able risk factors, and in such patients, a more detailed preoperative workup
and perioperative care are appropriate. Incentive spirometry reduces inci-
dence of complications, and the effect is maximum when it is started before
surgery. Using epidural analgesia as a method of postoperative pain control
and reducing the use of sedatives and narcotics are also helpful.
HOW TO DEAL WITH FEVER AFTER SURGERY?

First of all, you must remember that elevation of temperature after arthroplasty
can be a normal process as a part of body’s natural response to surgery. It
Total Joint Arthroplasty: Medical Parameters 5
has been shown that patient’s blood contains elevated amount of cytokines
(IL-1ơ, IL-6 and TNF Ơ) after total joint arthroplasties. Patients react to
these cytokines in a varied manner, and some patients may develop a rise in
temperature. However, fever can also occur due to infection at surgical site,
venous thromboembolism, pneumonia, atelectasis or urinary tract infection.
A recent study recommends against doing blood culture in such patients
because it is not helpful in management decisions, and it adds to health
care cost and delays discharge.2 In such a scenario, the clinical acumen of
the surgeon becomes more important in taking the call regarding when to
investigate further. Certain parameters have been proven to predict higher
positive fever evaluation, and these should be remembered as red flags –
fever developing after third postoperative day, fever lasting for multiple
days and a temperature higher than 39°C.3 Following these criteria, and
correlating with physical findings, one can decide when and how much to
investigate for fever in the postoperative period. C-reactive protein (CRP)
has a bimodal fall pattern after surgery, which normalizes by second to
third week. The CRP value on Day 4 is 80% reduction from the value on
Postoperative Day 1. The falling trend can reassure the surgeon that it is not
infective. Occasionally, procalcitonin values in early postoperative period
can be helpful to rule out infection. However, these are not routinely per-
formed due to high cost. Fever may not accompany the infection; more
often, copious persisting discharge is usually suggestive of infection.
Warning Box
If your patient has fever after surgery, don’t panic! A blood culture is often
not necessary. Remember the red flags – Onset after Postoperative Day 3,
Temperature > 39°C, Duration of multiple days. Do serial CRP and check
clinical findings at incision site.
HOW TO PREVENT DEEP VEIN THROMBOSIS

IN MY PATIENT?
The field of deep vein thrombosis (DVT) prophylaxis has been a confus-
ing and controversial one since the past many years. The guidelines by
the American College of Chest Physicians (ACCP) and the American
Association of Orthopedic Surgeons (AAOS) were in direct conflict with
each other till 2012. However, with recent revision of ACCP guidelines
(ninth revision, 2012), the major recommendations are largely clear. The
focus is now shifted to clinically symptomatic thromboembolic events
instead of asymptomatic venography detected episodes. The new guide-

lines recommend that all patients should receive prophylaxis (pharmacolog-
ic agent or intermittent pneumatic compression device, IPCD) for at least
10–14 days, which could be extended up to 35 days. The pharmacologic
agents include low molecular weight heparins (LMWH), fondaparinux,
apixaban dabigatran, rivaroxaban, aspirin and vitamin K antagonist.
Irrespective of the use of IPCD, the use of LMWH is recommended over
other pharmacologic agents. LMWH should be started either 12 h before
or after surgery instead of within 4 h of surgery. Dual prophylaxis (pharma-
cologic plus IPCD) and extending duration to 35 days are recommended
in cases of major orthopaedic surgeries. In patients who are at high risk
of bleeding, instead of using a pharmacologic agent, an IPCD or no pro-
phylaxis should be used. When IPCD use is not possible (uncooperative
patient/patient declines), apixaban or dabigatran should be used. There is
no need to do ultrasound screening in asymptomatic patients before hos-
pital discharge. The reader is directed to study the guidelines in detail4 and
commentaries5 on them, if interested.
Warning Box
Multimodal strategy is the best approach to tackle DVT prophylaxis. It
would also save the surgeon medicolegally. Regional anaesthesia, foot
pump/TED stockinette, early mobilization with or without chemical pro-
phylaxis can be helpful.
DOES MY PATIENT NEED ICU?

Unforeseen admission to ICU after joint arthroplasty can be a financial
and logistical problem for the health care provider in addition to being an
emotional burden for the family. Although perioperative and postoperative
monitoring can sometimes detect the need, it is best to predict future need
for ICU from preoperative and intraoperative factors. A study evaluating
22,343 arthroplasties has identified the risk factors as smoking, low haemo-
globin level, higher BMI, older age (>65), higher preoperative C reactive
protein, general anaesthesia, allogenic transfusion (3.5 times higher risk) and
cemented arthroplasty.6
Recently described Penn Arthroplasty Risk Score7 includes five inde-
pendent predictors, COPD, coronary artery disease, congestive heart failure
(1 point each), estimated blood loss >1000 mL and intraoperative vasopres-
sors (2 points each). The total score can vary from 0 to 7, with probability
of needing critical care increasing gradually as 7.0%, 13.2%, 23.5%, 38.1%,

55.4%, 71.4%, 83.4% and 91.1%.
WHICH ANTIBIOTICS, WHEN AND FOR HOW LONG?

This question is addressed in more detail in Chapter 4 on infection.
The choice of antibiotics should be undertaken after understanding the
common microbiological organism that contaminates surgical site in
your particular institution. AAOS recommends first generation cepha-
losporin (e.g., cefazolin) whereas in some other parts of world, cefurox-
ime is the prophylactic antibiotic of choice. There are published reports
of incidents wherein hospital infection control committees have moved
away from these recommendations to address the unique challenges
faced by them (e.g., vancomycin as a primary prophylaxis to tackle
high incidence of methicillin-resistant Staphylococcus aureus (MRSA)
and coagulase negative Staphylococcus).8 The author’s preference is to use
antibiotics recommended by the hospital infection control committee,
first dose given at least 30 min prior to tourniquet inflation, and not
beyond 24–48 h.
WHEN SHOULD I TAKE OUT THE URINARY CATHETER?

Bladder management in perioperative scenario often boils down to
choosing the lesser of two evils. On the one hand, both indwelling and
intermittent catheterization have risk of bacteremia, while on the other
hand, urinary retention leads to bladder atonia and residual urine, predis-
posing towards infection. In addition, the patient discomfort due to uri-
nary retention remains an additional concern. The other problems associ-
ated with prolonged urinary catheter include development of delirium,
higher risk of falls and difficult rehabilitation. Older research studies have
preferred indwelling catheters over ‘pro re nata’ straight catheterization
protocol.9,10 However, a relatively newer randomized prospective trial
favored intermittent catheterization.11
The author’s choice is to avoid indwelling catheter in all cases. In
short procedures (e.g., primary total knee replacement), any form of
catheterization is completely avoided. In other cases, as and when needed,
bladder evacuation with simple rubber catheter is done.
HOW TO MANAGE POSTOP COGNITIVE CHANGES?

Two types of cognitive changes are described in a postoperative setting.12
An acute and transient disturbance of mental function (with possibility
of affection of awareness) is known as delirium. The longer lasting and
subtle cognitive changes are labeled as postoperative cognitive dysfunc-
tion (POCD). POCD, although initially described in cardiac surgeries, is
now known to occur also after noncardiac surgeries, such as total knee
arthroplasty (TKA). Multiple theories have been proposed regarding
the cause of cognitive impairment, including general anaesthesia, post-
operative pain and analgesia, cerebral hypoperfusion and intraoperative
microemboli.13 Microemboli enters into the systemic circulation when
tourniquet is released and they reach cerebral circulation through patent
right-to-left intracardiac shunts or intrapulmonary passage. Isoflurane and
benzodiazepine should be used with caution, as they are associated with
increased risk of postoperative delirium.14 The other causes of delirium
include hypoxia, hypoglycemia, electrolyte imbalance, volume depletion,
infection and drug interaction. Management of postoperative delirium
includes general supportive care and specific measures as per the etiology.
The components of such care include adequate oxygen delivery, fluid
and electrolyte balance, appropriate pain management, early mobilization,
review/discontinuation of unnecessary medications and optimization of
environmental stimuli (proper sleep wake cycle, family members at bed-
side, glasses and hearing aids, etc.).15 Haloperidol is the most common
drug used for delirium in ICU setting. Gabapentin provides good pain
control without any risk of delirium. POCD is an area of active research
with controversies on possible link to Alzheimer’s disease. The reader is
advised to keep himself appraised with upcoming literature to stay ahead
of the curve in this issue.
HOW SHOULD I ACHIEVE GLYCEMIC CONTROL

PERIOPERATIVELY?
Many patients undergoing total joint arthroplasty (TJA) also have preexist-
ing diabetes mellitus. Attaining a tight glycemic control not only reduces
the risk of surgical site infection16 but also decreases mortality, following
MI.17 It is equally important to prevent hypoglycemic episodes. Patients
who are on insulin preoperatively should continue taking their basal insu-
lin; however, their shorter-acting insulin should only be administered after
blood glucose measurements before each dose. Oral medications are best
started after patient resumes normal oral intake.
HOW TO PREVENT ADDISONIAN CRISIS IN PATIENTS

ON LONGTERM STEROIDS?
A dose as low as 7.5 mg of prednisone (or equivalent) taken daily for 7 days
can suppress hypothalamic-pituitary-adrenal axis till 9 months.18 Patients
undergoing TJA may be on steroids for rheumatoid arthritis, collagen vas-
cular diseases or pulmonary conditions. In an ideal situation, adrenocorti-
cotropic hormone (ACTH) stimulation test should be done preoperatively
to assess the adrenal reserve. When not possible, it is safe to give stress dose
steroids to all such patients who have been on 7.5 mg or more of predni-
sone (for five or more days) at any point during last year. The stress dose
is gradually lowered to the standard dose in patients on chronic steroids.
DOES THE PERIOPERATIVE PROTOCOL DIFFER FOR

BILATERAL SINGLE STAGE?
Direct head-to-head comparison of complications of staged vs. single stage
bilateral TKA is difficult because often the patient groups are quite dif-
ferent. Nonetheless, single stage bilateral TKA are associated with higher
incidence of postoperative complications, especially cardiopulmonary.
Postoperative atrial fibrillation is one of the commonest complications
(4.8% in one series).19 Cardiac monitoring is thus more paramount in such
scenarios. The role of systemic inflammatory response in the development
of fat emboli syndrome and acute respiratory distress syndrome is being
understood increasingly. IL-6 (tissue marker for systemic inflammation) and
desmosin (markers of tissue damage in lung) decrease significantly when
corticosteroids are administered perioperatively.20 This has been proven to
reduce the incidence of fat embolism syndrome in long bone fractures21
and perhaps a similar benefit will be obtained in arthroplasty patients who
are at high risk. To summarize, appropriate patient selection, regional
anaesthesia, strict perioperative cardiac monitoring, control of systemic
inflammatory response, perioperative corticosteroids and early mobilization
are some of the special efforts required to guarantee a better outcome with
minimal complications in patients undergoing single stage bilateral TKA.
WHEN TO DISCONTINUE AND RESUME CLOPIDOGREL

IN PATIENTS WITH CARDIAC STENTS?
Dual antiplatelet therapy is the standard recommendation for the preven-
tion of stent thrombosis by AHA and ACC. This usually includes aspirin
and clopidogrel, continued for 30–45 days after bare metal stent placement
and for 365 days after placement of a drug eluting stent. While it is clearly
known that discontinuation of antiplatelet therapy within this timeframe
increases the risk of acute stent thrombosis, there are no clear guidelines
for clopidogrel use/discontinuation after these time periods. A recent
research study concludes that patients continuing clopidogrel periopera-
tively are more likely to need blood transfusions without any decrease in
the incidence of adverse cardiac events (it was actually higher in clopidogrel
continuation group, although not statistically significant). It is possible that
patients at higher risk of developing adverse cardiac events were allowed
to continue clopidogrel (the study was not randomized), or it is likely that
allogenic blood transfusion led to the increase in proinflammatory and
prothrombotic mediators. Due to existing contradictory literature,22,23 the
author is far from the goal of the providing absolute recommendations.
However, should the team feel the need to continue clopidogrel in view of
serious cardiac risks, the possibility of increased blood transfusion and risk
of adverse cardiac events should be anticipated.
WHEN SHOULD I REMOVE THE EPIDURAL CATHETER

IN A PATIENT ON LMWH?
One often has to face the challenge of optimally timing neuraxial analgesia
(e.g., continuous epidural analgesia) when the patient is on anticoagulants/
antiplatelets. Although the decision to use or not use neuraxial analgesia
and the timing of catheter removal is best done by individualization based
on patient profile,24 there are certain recommendations available to guide
us in that decision making process. Low molecular weight heparin dosing
practices differ geographically; twice daily dosing is common in North
America, while once daily dosing is prevalent in Europe. There are studies
that suggest that higher anticoagulant activity is present during epidural
catheter removal in patients receiving twice daily dosing.25
Irrespective of once- or twice-daily schedule, there should always be
a gap of 2 h between the catheter removal and the next dose of LMWH.
When a twice-daily dosing is planned, the first dose of LMWH should
be administered 2 h after the catheter removal or 24 h after the catheter

placement, whichever is later.24 In this setting (i.e., twice-daily dosing),
catheter is best removed before starting LMWH. However, if that is not
possible, then one should wait for >24 hours after the last dose to remove
the catheter. When using once-daily dosing of LMWH, catheter can be
removed anytime, that is, 12 h after the administration of LMWH. A gap
of 6–8 h between the catheter placement and first dose of LMWH should
be present, with subsequent dosing occurring no sooner than 24 h after
the first dose.24
HOW DO OBESITY AND METABOLIC SYNDROME

AFFECT MY RESULTS?
In addition to leading to early development of osteoarthritis, obesity also
causes many complications in patients undergoing arthroplasty. While arthro-
plasty relieves the pain and functional disability associated with osteoarthritis
in obese patients, the risks are also high. Hence an orthopaedic surgeon
must understand when to intervene and when to leave arthroplasty out of
the options when facing obese patients. Wound healing is affected in obese
patients, with a higher rate of infection in both TKA and THA. In TKA
performed on obese patients, risk of in-hospital wound problem doubles and
the risk of deep infection is increased three times (Fig. 1.1).26
Fig. 1.1 Clinical photograph of delayed wound healing and

superficial infection after total knee arthroplasty (TKA) in an
obese female patient.
Many obese patients also suffer from comorbidities like obstructive

sleep apnea, hypertension, cardiac diseases and diabetes mellitus. These
patients are at high risk to suffer thrombosis, pulmonary embolism and
sudden cardiac death after TJA. Obesity also leads to arthroplasty-specific
complications such as component malposition, prosthesis loosening, higher
incidence of dislocation and earlier need for revision surgery.
As far as functional results after TJA is concerned, obese patients tend
to have lower quality of life and performance compared to nonobese
patients. Nonetheless, arthroplasty does improve the functional status from
the preoperative level, and the patient satisfaction level shows no difference
between the obese and nonobese, suggesting that TKA may still be the
best treatment for most obese patients. In many obese patients, particu-
larly those with BMI >40, the functional improvements occur at a slower
pace, which needs to be discussed with the patient before the procedure.
In morbidly obese (BMI >40) and super-obese (BMI >50), often the risks
of complications are too high. In such patients, the surgeon must consider
delaying the surgery and starting a weight-loss program.
Many obese individuals have insulin resistance associated with altered
adipose deposition and function. These patients often have associated
comorbidities that are grouped together as metabolic syndrome. Metabolic
syndrome is defined as a BMI >30 kg/m2 in addition to any two of the fol-
lowing: hyperlipidemia, hypertriglyceridemia and hypertension or diabetes.
Coronary artery diseases and thromboembolism are common in individuals
with metabolic syndrome. Insulin resistance seen in metabolic syndrome
is believed to be responsible for causing endothelial dysfunction, leading
to complications, which are higher compared to patients who are obese
but not suffering from metabolic syndrome. Hence, in addition to obesity,
metabolic syndrome appears to be an additional and unique risk factor for
both in-hospital and long-term complications after TJA, requiring early
identification and appropriate patient optimization.
TAKE HOME MESSAGE

The elderly population forms a large chunk of TJA cases operated, and the
number is growing every year. Despite being a largely effective and successful
group of surgeries, TJAs are associated with certain serious perioperative
and postoperative complications. It is prudent for arthroplasty surgeons to
familiarize themselves with these potential pitfalls. Considering the fact
that most of the complications are preventable or salvageable with preop-
erative screening, planning and timely intervention, there is no excuse for

not achieving the best possible standards. Arthroplasties are often described
as a highly effective surgical intervention, and we believe, it is important for
us to make them highly safe also.
REFERENCES
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2. Bindelglass DF, Pellegrino J. The role of blood cultures in the acute evaluation of post-
operative fever in arthroplasty patients. J Arthroplasty 2007;22(5):701–2. PubMed PMID:
17689779.
3. Ward DT, Hansen EN, Takemoto SK, Bozic KJ. Cost and effectiveness of postoperative
fever diagnostic evaluation in total joint arthroplasty patients. J Arthroplasty 2010;25(6
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4. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL,
Pauker SG, Colwell CW Jr; American College of Chest Physicians. Prevention of VTE
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6. AbdelSalam H, Restrepo C, Tarity TD, Sangster W, Parvizi J. Predictors of intensive
care unit admission after total joint arthroplasty. J Arthroplasty 2012;27(5):720–5. doi:
10.1016/j.arth.2011.09.027. Epub 2011 Nov 15. PubMed PMID: 22088781.
7. Courtney PM, Whitaker CM, Gutsche JT, Hume EL, Lee GC. Predictors of the
need for critical care after total joint arthroplasty: an update of our institutional risk
stratification model. J Arthroplasty 2014; pii:S0883-5403(14):00142–9. doi: 10.1016/j.
arth.2014.02.028. [Epub ahead of print] PubMed PMID: 24703365.
8. Smith EB,Wynne R, Joshi A, Liu H, Good RP. Is it time to include Vancomycin for rou-
tine perioperative antibiotic prophylaxis in total joint arthroplasty patients? J Arthroplasty
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9. Oishi CS, Williams VJ, Hanson PB, Schneider JE, Colwell CW Jr, Walker RH.
Perioperative bladder management after primary total hip arthroplasty. J Arthroplasty
1995;10(6):732–6. PubMed PMID: 8749753.
10. Knight RM, Pellegrini VD Jr. Bladder management after total joint arthroplasty. J
Arthroplasty 1996;11(8):882–8. PubMed PMID: 8986564.
11. Van den Brand IC, Castelein RM.Total joint arthroplasty and incidence of postoperative
bacteriuria with an indwelling catheter or intermittent catheterization with one-dose
antibiotic prophylaxis: a prospective randomized trial. J Arthroplasty 2001;16(7):850–5.
PubMed PMID: 11607900.
12. Hovens IB, Schoemaker RG, van der Zee EA, Heineman E, Izaks GJ, van Leeuwen
BL. Thinking through postoperative cognitive dysfunction: How to bridge the gap
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doi: 10.1016/j.bbi.2012.06.004. Epub 2012 Jun 21. Review. PubMed PMID: 22728316.
13. Scott JE, Mathias JL, Kneebone AC. Postoperative cognitive dysfunction after total
joint arthroplasty in the elderly: a meta-analysis. J Arthroplasty 2014;29(2):261–7.e1. doi:

10.1016/j.arth.2013.06.007. Epub 2013 Jul 23. PubMed PMID: 23890520.
14. Nandi S, Harvey WF, Saillant J, Kazakin A, Talmo C, Bono J. Pharmacologic risk fac-
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15. Flinn DR, Diehl KM, Seyfried LS, Malani PN. Prevention, diagnosis, and management
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16. Golden SH, Peart-Viligance C, Kao WH, et al. Perioperative glycemic control and
the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care
1999;22:1408.
17. Malmberg K, Ryden L, Efendic S, et al. Randomized trial of insulin- glucose infusion
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18. Graber AL, Ney RI, Nicholson WE, et al. Natural history of pituitary adrenal recovery
following long-term suppression with glucocorticoids. J Clin Endocr Metab 1965;25:11.
19. Pavone V, Johnson T, Saulog PS, Sculco TP, Bottner F. Perioperative morbidity in bilateral
one-stage total knee replacements. Clin Orthop Relat Res 2004;421:155– 61.
20. Sculco TP, Sculco PK. Simultaneous-bilateral TKA: double trouble - opposes. J Bone
Joint Surg Br 2012;94(11 Suppl A):93–4. doi: 10.1302/0301-620X.94B11.30829.
21. Bederman SS, Bhandari M, McKee MD, Schemitsch EH. Do corticosteroids reduce the
risk of fat embolism syndrome in patients with long-bone fractures? A meta-analysis.
Can J Surg 2009;52:386–93.
22. Grujic D, Martin D. Perioperative clopidogrel is seven days enough? Am Surg
2009;75:909.
23. Kang W, Theman TE, Reed III JF, et al. The effect of preoperative clopidogrel on bleed-
ing after coronary artery bypass surgery. J Surg Educ 2007;64:88.
24. Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and
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25. Douketis JD, Kinnon K, Crowther MA. Anticoagulant effect at the time of epidural
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2002;88(1):37-40. PubMed PMID: 12152674.
26. Workgroup of the American Association of Hip and Knee Surgeons Evidence Based
Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty
2013;28(5):714–21. doi: 10.1016/j.arth.2013.02.011. Epub 2013 Mar 19. Review.
Chapter 2
Blood Transfusion Reduction in

Total Joint Arthroplasty
Alisina Shahi, Javad Parvizi
INTRODUCTION
Due to the high levels of blood loss associated with the procedures, ortho-
paedic surgery commonly requires allogeneic blood transfusions. This is a
concern, particularly with older patients who are at higher risk of intraop-
erative haemorrhage. Although banked blood has become increasingly safe,
transfusion has been identified as an independent risk factor for adverse
outcomes.1 Additionally, homologous donation may be a limited resource
for many health care centers because blood banks regularly undergo short-
ages.2,3 In response, various predonation and salvage mechanisms and
pharmacological methods to mitigate blood shed have been introduced.
While the popularity of preoperative autologous donation has declined for
logistical reasons, erythropoietin (EPO) and perioperative autologous blood
salvage strategies have increased in popularity.4 Still, homologous transfu-
sion remains the gold-standard approach for increasing blood cell count in
anaemic patients in the perioperative period.
Erythrocyte transfusion is associated with a considerable impact on
morbidity. Studies have shown that blood transfusions are linked to signifi-
cant short- and long-term risks including stroke, renal failure, myocardial
infarction and death,1 as well as infection and allergic reactions,5 and the
nebulous transfusion-related acute lung injury (TRALI). Reducing these
risks by minimizing both intraoperative and postoperative blood loss and
consequent transfusion requirement remains an important element of
patient care for the orthopaedic surgeon.
The number of blood transfusions can be reduced through proper
surgical planning, patient management and overall thoughtful care. For
instance, it is essential to follow blood conserving techniques, including
anaemia and haemostasis management. Preoperative patient ‘optimization’
is important. A range of factors such as lifestyle, many comorbidities, anae-
mia, sarcopenia and medications are modifiable, and can be optimized to
reduce perioperative morbidity.5 Certain perioperative medications can be
used to reduce blood loss and transfusion requirement. Lastly, intraopera-

tive and postoperative salvage mechanisms and positioning techniques are
potentially effective methods of reducing blood loss.
Achieving optimal patient outcomes can be made possible through a
well-planned, multidisciplinary, patient-centered approach to care.6 The goal
of this chapter is to provide information regarding the currently available
medications, interventions and techniques that can be utilized in orthopaedic
surgical procedures to reduce allogeneic erythrocyte consumption.
PREOPERATIVE STRATEGIES
According to the World Health Organization (WHO), 10.5% of orthopae-
dic surgery patients are diagnosed with marked anaemia.7 Bierbaum et al.
found that more than 35% of patients in the United States had haemoglobin
(Hb) levels of 13 g/dL or less, and that a baseline Hb below this level was
associated with the highest rates of transfusion of allogeneic blood.8 There
is mounting literature evidence supporting the notion that preoperative
anaemia increases the risk of postoperative morbidity and mortality, in addi-
tion to impairing functional recovery and reducing the quality of life.9–12
In order to increase the number of erythrocytes in circulation, preop-
erative medications such as erythropoietin-stimulating agents (ESAs) and
synthetic EPO can be administered. However, these medications must
be used with caution and only patients with sufficiently low Hb levels
should be prescribed ESAs or EPO. When given to patients with higher
Hb levels (typically above 13 g/dL),13 the risk of polycythaemia increases.
Polycythaemia can lead to complications such as haemorrhage, thrombosis
and cardiac failure. Although the increased risk of such complications as
related to medications is somewhat controversial, the risk of thrombosis
in orthopaedic operations is significantly high regardless of the treatment
regimen.14,15 For this reason, it is recommended to minimize ESA and EPO
utilization in association with orthopaedic procedures.
Erythropoietin
EPO is an innate cytokine hormone produced by interstitial fibroblasts in
the kidneys. Renocortical interstitial cells release endogenous EPO into
the bloodstream when the circulating oxygen tension is low. EPO plays a
role in recruiting and differentiating erythroid progenitor cells and assisting
with their survival, and also stimulates Hb synthesis.16 The most commonly
Blood Transfusion Reduction in Total Joint Arthroplasty 17
used synthetic form of EPO is epoetin alpha, which is made up of the same
amino acid sequence, and therefore, exerts identical biological activity as
endogenous EPO. In conjunction with endogenous EPO, epoetin alpha is
capable of safely stimulating the synthesis of Hb.13,17
To effectively boost erythrocyte production, EPO should be combined
with either oral or intravenous iron supplementation.18 Three injections of
EPO are typically administered over a 3-week period prior to the surgery,
and the fourth one is given in the operating room immediately following
the operation. The dosage of EPO is either 300 IU/kg/day over 15 days, or
600 IU/kg over 4 weeks, starting 3 weeks before the procedure (Fig. 2.1).
It is best to give these injections subcutaneously rather than intravenously
because the subcutaneous method slows release, yielding a more consistent
sustained plasma level.16
Pretreatment
Hb
>10 to ) 13 g/dL )10 or >13 g/dL
If the preoperative Not a candidate for

period is <3 wk, treat epoetin alpha
with epoetin alpha therapy
20,000 U* (300 U/kg)
10 d preoperativley, on
the day of surgery, and
4 d postoperatively
If the preoperative period

is *3 wk, treat with
epoetin alpha 40,000 U*
(600 U/kg) on days -21,
-14, and -7, and the day
of surgery
Fig. 2.1 Treatment algorithm for use of epoetin alpha in anaemic patients scheduled
for elective, non-cardiac, non-vascular surgery at high risk for transfusion because of
anticipated blood loss. *Based on patient weight of 70 kg.¹⁹
Although EPO is costly, the effectiveness of this medication in elevating

Hb levels is compelling. Preoperative treatment with EPO has been shown to
increase blood cell mass, Hb and haematocrit levels and to decrease transfusion
rate significantly.15,20,21 A recent study followed a cohort of patients undergo-
ing total hip replacement with low Hb who received 600 IU/kg epoetin beta
over a 4 week period. Only 3.6% of patients in the treatment group required
a transfusion, compared to a group of patients not administered EPO, 45.2% of
which required transfusions. In a control group with normal levels of Hb, the
transfusion rate was 11.9%. The authors concluded that a 92% reduction in
transfusions was evident with the administration of EPO.2
However, the cost–benefit analysis is less encouraging. In 1998, Coyle
et al. published an economic analysis of EPO use for orthopaedic surgery
in Ottawa, Canada. Among other results, they found that EPO used led to
only modest benefits when compared to both no intervention and as an
augmentation to preoperative autologous donation. From a cost-effective-
ness perspective, the authors concluded that EPO administration to reduce
perioperative allogeneic transfusions for orthopaedic patients ‘did not meet
criteria conventionally considered acceptable.’21
A similar recent randomized control trial evaluated EPO and blood sal-
vage as transfusion alternatives in adult elective hip- and knee-arthroplasty
patients in Leiden, the Netherlands. The authors found a reduction in mean
erythrocyte usage, and a significant decrease in the proportion of patients
transfused, when a restrictive transfusion threshold of 8 g/dL was used.
In this report, the optimal benefit for EPO to decrease transfusions was
observed in patients with preoperative Hb levels of 10 to 13 g/dL. The
authors similarly found that EPO increased costs substantially, in this case
by €785 per patient, or €7300 per transfusion avoided, concluding that
EPO avoids transfusion significantly but at ‘unacceptably high costs.’4
Iron, Vitamin B₁₂ and Folic Acid

Iron deficiency accounts for approximately one-half of anaemia cases and
is the most common nutritional disorder worldwide.23 An estimated 25%
of the total world population is affected by iron-deficiency anemia (IDA).
Excluding parasitosis, most cases are due to inadequate intake, increased
ferric requirement, or related to blood loss or disease states.
Iron is necessary for oxygen transport in the bloodstream. The human
body contains approximately 4–5 g of iron, 65% of which is bound by Hb
and unavailable for use in erythropoiesis. Around 15–30% of the iron can
be found in the hepatic parenchyma and the reticuloendothelial system,
stored as ferritin. The remainder of total body iron is circulating in the

blood plasma, largely bound to transferrin.
Appropriate levels of iron, vitamin B12 and folic acid are required for
erythropoiesis to take place. If a patient is deficient in any of those elements,
cellular differentiation and proliferation are negatively affected, leading to
central aregenerative anaemia. Another form of anaemia, termed functional
iron deficiency, is when the body possesses adequate iron levels, yet there
is insufficient iron available to the bone marrow to adequately support the
needs of erythroid precursors. When chronic inflammation blocking the
transfer of stored iron, this form is referred to as anaemia of chronic dis-
ease, and may be caused by a proinflammatory cytokine-mediated effect on
erythropoiesis. In functional iron deficiency, serum ferritin levels may be
normal or elevated, yet the red blood cell count continues to be diminished.
Iron consumption is an essential adjuvant to EPO treatment, and may also
be administered prior to autologous predonation to optimize the haemogenesis
processes. The iron dosage can be determined based on the initial Hb levels
and the presence or absence of total iron deficiency. Oral administration of iron
has been reported to have a beneficial effect on reducing the number of neces-
sary allogeneic blood transfusions.24 However the availability of orally admin-
istered iron is affected by various factors that reduce iron absorptive capacity
and by gastric disorders that interfere with iron uptake, such as inflammatory
bowel disease.25 In these cases, it may be necessary to deliver iron treatment
intravenously. Due to some associated risks and side effects, once the intrave-
nous administration is no longer necessary, it is recommended to switch to oral.
Because PO iron supplementation is more convenient than intravenous, it is
generally preferred for orthopaedic surgery patients without iron deficiency
when EPO treatment is considered.13
Autologous Blood Predonation

It is common for surgical patients to have lower Hb count on the day of the
surgery than a previous reading, prompting the need for a transfusion. In
the days or weeks leading to surgery, a phlebotomy may be performed and
the extracted blood collected can be used during or after the procedure.
Although autologous predonation can increase the chance of a transfusion
requirement, it is considerably safer than homologous transfusion because
there is much lower risk of rejection, blood incompatibility and infection.
These donations may be carried out multiple times prior to surgery, in
recommended intervals of not shorter than 3 days (350–400 mL each time).
In this manner, there is ample time for protein synthesis and haematogen-
esis to occur between donations; again appropriate iron supplementation

should be administered. The storage of donated blood is the same as for
allogeneic transfusions, requiring meticulous record-keeping and an exten-
sive collection system, and the use is generally limited to hospitals with
established blood bank capabilities. However, because the predonation is
not typically tested, typed or screened, the harvested blood may not be kept
and used for other patients.
Certain criteria must be met to be eligible for predonation. First, Hb
level greater than 11 mg/dL is required because the donation introduces an
acute iron deficiency anaemia with all related signs and symptoms includ-
ing fatigue, headache, syncope, shortness of breath, angina, intermittent
claudication and palpitations. Second, a well-planned surgery is recom-
mended as the extracted blood unit(s) carry an ‘expiration date.’ Storage
time is known to be the most important factor related to cell quality,
and therefore, predonation should be done no more than 35 days before
surgery. Because autologous predonation is exposed to the same potential
errors in processing, storage and identification, the following are contra-
indications for the procedure: history of serious cardiac disease, history of
hepatitis B or C or positive markers for hepatitis C virus (HCV), human
T-cell lymphotropic virus (HTLV) or human immunodeficiency virus
(HIV) and active bacterial infection.
INTRAOPERATIVE STRATEGIES
To improve the effectiveness of intraoperative strategies, the following
recommendations should also be associated with preoperative optimiza-
tion whenever possible. Performing the operation using minimally invasive
techniques has been shown to reduce overall blood loss and should be
employed whenever possible.
Individualized Transfusion Threshold

Most physicians would recognize the importance of following a strict
transfusion protocol, with a threshold for transfusion at Hb levels of 7 g/dL.
Additional complexities such as anaemia from disease states should be taken
into consideration on a case-by-case basis. In some instances, the transfu-
sion threshold may be lowered, delaying the initiation of the transfusion
until the surgery’s completion. However, it is imperative that patients with
Hb levels at or below 6 g/dL undergo transfusion.
Normovolemic Dilution
Similar to autonomic predonation, this strategy involves drawing the
patient’s own blood. In this method, the phlebotomy is performed either
shortly before or during the operation; typically 0.5–1.5 L of blood is
extracted, and an equal volume of colloid or crystalloid solution is infused
to replace it. In this way, the haemorrhage contains fewer erythrocytes, and
therefore, the total blood loss is less significant. If necessary, the extracted
blood may be returned to the patient as an autologous transfusion.
A study performed by Davies et al. concluded that acute normovole-
mic dilution is a cost-effective technique for reducing allogeneic blood
transfusions.25 Goodnough et al. similarly compared acute normovole-
mic haemodilution to preoperative autologous donation in total hip
arthroplasty patients and concluded that normovolemic haemodilution
is considered safe. Although there were no differences between the two
groups regarding the requirement for allogeneic blood transfusion, acute
normovolemic haemodilution was dramatically more cost-effective than
preoperative autologous blood donation.10
Autotransfusion
The use of autotransfusion systems are gaining in popularity. These sys-
tems are available in several categories and are known by a variety of
terms including ‘cell saver,’ ‘cell washers,’ ‘RBC-savers,’ direct transfusion
and ultrafiltration of whole blood. In some systems, the aspirate under-
goes centrifugation and is ‘washed’ with 9% sodium chloride. In others,
the content is unwashed and simply returned to the patient after pass-
ing through a filter. Cell savers are routinely used during orthopaedic
procedures in the United States and have become increasingly popular
worldwide.
The use of a cell saver may recover up to 70% of the intraoperative
blood shed in an orthopaedic procedure.27 This has the potential to sig-
nificantly reduce transfusion requirements. However, the results from a
recent randomized control trial revealed that autologous blood reinfusion
failed to decrease mean erythrocyte use, and did not result in a smaller
proportion of transfused patients. The authors reasoned this may be due to
the relatively low visible blood loss, and hence, low volume of recovered
blood. Reinfusion was also associated with an increased length of hospital
stay, albeit in non-intensive care. Hence, autotransfusion can potentially
reduce overall blood loss but may not be cost-effective.4,28
Anaesthetic Measures
Anaesthetic approaches are mainly related to pain management and blood
volume maintenance, as well as controlling heart rate and high blood
pressure. Hyperoxic ventilation can be used to improve oxygen transport
in patients with low Hb levels. Optimal patient positioning during sur-
gery can reduce venous congestion. It is also recommended that regional
anaesthesia be used whenever possible, as several studies have demon-
strated decreased perioperative bleeding compared to general anaesthe-
sia.29,30 This effect is believed to be related to the lower blood pressure.
Other anaesthesiological methods such as normothermia management,
normovolemic dilution and controlled hypotension can also play a role
in reducing blood loss.
Although still controversial, it has been shown that lowering the blood
pressure can be relatively effective in reducing the amount of blood shed
throughout the course of surgery. Related contraindications consist of
untreated high blood pressure, serious lung disease, coronary disease, sig-
nificant polycythemia, severe anaemia, cerebrovascular disease, serious liver
or kidney dysfunction and pregnancy. Various drugs are used to control
hypertension, the most common of which are inhalers (isoflurane, sevoflu-
rane), beta blockers (esmolol, labetalol), direct acting vasodilators (sodium
nitroprusside, nitroglycerin) and others such as urapidil and captopril.
Antifibrinolytic Agents
Antifibrinolytic agents (AFAs) may be used preoperatively, intraoperatively or
postoperatively, and have been shown to have a dramatic effect on blood loss
and transfusion requirement. Agents such as aprotinin, lysine analogs such as
tranexamic acid (TXA) and Ƥ-aminocaproic acid (EACA) are widely used,
particularly for cardiac surgery. AFAs have been shown to enhance haemostasis
by interfering with fibrinolysis and thus are believed to reduce blood loss.3,31
Previous reviews have found that these medications were effective in reducing
blood loss, transfusion requirement and reoperations due to bleeding.32 However,
many studies performed to-date were either underpowered or performed for
other specialties such as cardiac surgery.3 Hence, the effect of AFAs on reducing
blood loss specifically for arthroplasty remains relatively less explored.
A recent review article investigated the use of antifibrinolytics in ortho-
paedics by examining 43 randomized control trials in various operations
including spinal fusion, hip and knee arthroplasty, tumour and musculo-
skeletal sepsis. The authors found a significant reduction in the proportion
of patients requiring allogeneic transfusion associated with aprotinin and

TXA, whereas EACA was not effective.3 A 2011 Cochrane review article
on the subject concluded that ‘anti-fibrinolytic drugs provide worthwhile
reductions in blood loss and the receipt of allogeneic red cell transfusion.’
Aprotinin, previously the most popular agent, was withdrawn from the
market in 2008 due to concerns about cardiovascular complications. While
aprotinin was slightly more effective, the lysine analogues appear to be safe
and effective in reducing blood loss during and after surgery.32
Tranexamic Acid
TXA, a synthetic derivative of the amino acid lysine, is perhaps the most pop-
ular AFA currently used for orthopaedic surgery. A recent review article on
patients undergoing total knee arthroplasty examined 15 randomized control
trials, finding that TXA reduced total blood loss by 487 mL, intraoperative
loss by 127 mL and postoperative blood loss by 245 mL, with a significant
reduction (56%) in patients requiring transfusion. In addition, there were no
apparent differences in risk of thrombotic or embolic complications.31
Haemostasis
It is necessary for surgical haemostasis to be thoroughly performed during
each operation. With regards to orthopaedic surgery, the most commonly
used method is electrocautery. Another potential method of haemostasis,
intra-articular epinephrine injection, can also reduce bleeding but might be
associated with skin necrosis.5,33
Fibrin Spray
A newer method of haemostasis is topical fibrin spray (FS), a mixture of
thrombin and fibrinogen that is believed to control bleeding, improve tissue
healing and increase postoperative recovery rate.34 Fibrin sealer was shown
to reduce perioperative and postoperative blood loss after primary total
hip replacement compared to controls and treatment with bipolar sealer.35
This reduction was significant at every time interval measured, and the
volume saved was comparable to one unit of blood at each 24 and 48 h
with a total savings of 1735 mL.35 McConnell et al. found that both TXA
at induction and intraoperative topical FS reduced blood loss relative to a
control group, and that neither active treatment was superior. In a similar
study of computer-navigated cemented primary knee arthroplasty patients,
10 mL of FS effectively reduced blood loss compared to a control group,
but the effect of a 10 mg/kg bolus of TXA did not reach significance.35 A
recent meta-analysis on its use in TKA before wound closure concluded

that fibrin sealant was safe and effective, reduced postoperative drainage and
drop in Hb levels, reduced haematoma formation and transfusion require-
ment and did not increase adverse events.34 However, it was acknowledged
that limited literature was available and additional randomized control tri-
als on the subject were recommended.34 Furthermore, the use of FS may
reduce overall blood loss and length of hospital stay and increase postopera-
tive range of motion, although not statistically significantly.34
Tourniquets
Additional viable methods for surgical haemostasis include tourniquets and
exsanguination, but they must be used with caution. Tourniquets are often
used in total knee arthroplasty in order to decrease intraoperative blood
loss.37-39 A study performed recently by Zhang et al. demonstrated a reduc-
tion in intraoperative bleeding; however, there was a dramatic increase in
blood shed during the postoperative period.38 Similarly, a systematic review
by Smith and Hing concluded that tourniquets were associated with a sig-
nificant decline in intraoperative blood loss compared to procedures in which
tourniquets were not used. However there was no difference in total blood
loss between the two groups, and there was a somewhat higher frequency of
complications in the tourniquet group.37 Hence, tourniquets should be used
judiciously. While there is a clear positive impact in controlling operative
blood loss, the levels of postoperative bleeding tend to increase with tourni-
quets, as well as the risk of other complications.
POSTOPERATIVE STRATEGIES
In addition to the aforementioned, several postoperative strategies can be
employed to reduce blood loss. These methods may be particularly beneficial
to TKR patients due to the quantity of blood loss in the postoperative period.
Drainage Reinfusion
Similar to autotransfusion systems, postoperative drainage and reinfusion
devices involve reinfusion after the content has passed through a filter
mechanism, and typically employ continuous or intermittent vacuum
pressure. These systems are gaining popularity worldwide due to their
efficacy, feasibility and relatively low cost. However, a randomized
control trial performed in the Netherlands explored the use of a drain
system and found results similar to those with cell saver systems, namely,
a statistically significant decrease in transfusion requirement but also

increased length of hospital stay by nearly one whole day. The authors
concluded that ‘autologous blood salvage devices were not effective’
overall and that use of these devices increased costs and did not reduce
erythrocyte use. This was a two-part report, and these results were
observed for patients with preoperative Hb levels 10–13 g/dL as well as
patients with Hb greater than 13 g/dL.4,28
CONCLUSION
Many strategies can be employed to reduce blood loss in the orthopaedic
patient. Comorbidity management and patient optimization should be
employed whenever possible for patients undergoing elective procedures.
Preoperative iron deficiency anaemia should be controlled with appropri-
ate supplements. EPO may be used when oral or intravenous supplementa-
tion fails and has been shown to reduce transfusions; the optimal benefit for
EPO is seen in patients with 10–13 g/dL Hb. However, EPO is excessively
costly and its use may be unfeasible for many patients or treatment centers.
Autologous predonation is potentially safer than homologous transfusion
and may be performed whenever a transfusion requirement is anticipated.
This strategy requires proper planning and storage and its use has been
declined due to cost and logistic reasons. Tourniquets and exsanguination
may be used judiciously; while a tourniquet can lessen intraoperative blood
loss, bleeding tends to increase postoperatively and complications may be
higher. Procedures should be performed with minimally invasive tech-
niques whenever possible and using blood-conserving techniques including
meticulous haemostasis. The use of TXA appears to be safe and effective
in reducing perioperative blood loss without increasing adverse outcomes.
FS has been shown to reduce bleeding following both hip and knee arthro-
plasty and may reduce overall blood loss and number of transfusions. Both
TXA and FS seem to reduce haematoma formation. Anaesthetic measures
such as hyperoxic supplementation and patient positioning may be of some
value. Lowering the blood pressure intraoperatively is controversial but has
potential to reduce blood shed in select patients. Postoperative knee flex-
ion or leg elevation appears to be beneficial. Autotransfusion and drainage
reinfusion devices have the potential to ‘recycle’ shed blood and reduce
transfusion requirements but may not be cost-effective overall.
REFERENCES
1. Rawn J. The silent risks of blood transfusion. Curr Opin Anaesthesiol 2008;21(5):664–8.
2. Laffosse J-M, Minville V, Chiron P, Colombani A, Gris C, Pourrut J-C, et al. Preoperative
use of epoietin beta in total hip replacement: a prospective study. Arch Orthop Trauma
Surg 2010;130(1):41–5.
3. Zufferey P, Merquiol F, Laporte S, Decousus H, Mismetti P, Auboyer C, et al. Do anti-
fibrinolytics reduce allogeneic blood transfusion in orthopedic surgery? Anesthesiology.
2006;105(5):1034–46.
4. So-Osman C, Nelissen RGHH, Koopman-van Gemert AWMM, Kluyver E, Pöll RG,
Onstenk R, et al. Patient blood management in elective total hip- and knee-replacement
surgery (Part 1): A randomized controlled trial on erythropoietin and blood salvage as
transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible
patients. Anesthesiology 2014;22.
5. Napier RJ, Bennett D, McConway J, Wilson R, Sykes AM, Doran E, et al. The influence
of immediate knee flexion on blood loss and other parameters following total knee
replacement. Bone Jt J 2014;96-B(2):201–9.
6. Seeber P, Shander A. History and Organization of Blood Management. Basics of Blood
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7. Bisbe E, Castillo J, SAEz M, Santiveri X, RuIZ A, MuNOz M. Prevalence of preopera-
tive anemia and hematinic deficiencies in patients scheduled for elective major ortho-
pedic surgery. Transfus Altern Transfus Med 2008;10(4):166–73.
8. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis
of blood management in patients having a total hip or knee arthroplasty. J Bone Joint
Surg Am 1999;81(1):2–10.
9. Beattie WS, Karkouti K, Wijeysundera DN, Tait G. Risk associated with preop-
erative anemia in noncardiac surgery: a single-center cohort study. Anesthesiology
2009;110(3):574–81.
10. Goodnough LT, Despotis GJ, Merkel K, Monk TG. A randomized trial comparing acute
normovolemic hemodilution and preoperative autologous blood donation in total hip
arthroplasty. Transfusion (Paris) 2000;40(9):1054–7.
11. Conlon NP, Bale EP, Herbison GP, McCarroll M. Postoperative anemia and qual-
ity of life after primary hip arthroplasty in patients over 65 years old. Anesth Analg
2008;106(4):1056–1061, table of contents.
12. Gruson KI, Aharonoff GB, Egol KA, Zuckerman JD, Koval KJ. The relationship
between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma
2002;16(1):39–44.
13. Earnshaw P. Blood conservation in orthopaedic surgery: the role of epoetin alfa. Int
Orthop 2001;25(5):273–8.
14. De Andrade JR, Jove M, Landon G, Frei D, Guilfoyle M,Young DC. Baseline hemoglobin
as a predictor of risk of transfusion and response to Epoetin alfa in orthopedic surgery
patients. Am J Orthop 1996;25(8):533–42.
15. Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on
perioperative transfusion requirements in patients having a major orthopaedic operation.
The American Erythropoietin Study Group. J Bone Joint Surg Am 1996;78(1):62–72.
16. Erslev AJ. Erythropoietin. N Engl J Med 1991;324(19):1339–44.
17. Storring PL, Gaines Das RE. The International Standard for Recombinant DNA-
derived Erythropoietin: collaborative study of four recombinant DNA-derived
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1992;134(3):459–84.
18. García-Erce JA, Cuenca J, Haman-Alcober S, Martínez AA, Herrera A, Muñoz M.
Efficacy of preoperative recombinant human erythropoietin administration for reduc-
ing transfusion requirements in patients undergoing surgery for hip fracture repair. An
observational cohort study. Vox Sang 2009;97(3):260–7.
19. Deutsch A, Spaulding J, Marcus RE. Preoperative epoetin alfa vs autologous blood
donation in primary total knee arthroplasty. J Arthroplasty. 2006;21(5):628–35.
20. Faris PM, Ritter MA. Epoetin alfa. A bloodless approach for the treatment of periopera-
tive anemia. Clin Orthop 1998;(357):60–7.
21. Coyle D, Lee KM, Fergusson DA, Laupacis A. Economic analysis of erythropoietin use
in orthopaedic surgery. Transfus Med 1999;9(1):21–30.
22. Short MW, Domagalski JE. Iron deficiency anemia: evaluation and management. Am
Fam Physician 2013;87(2):98–104.
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supplementation and intraoperative transfusion during colorectal cancer surgery. Surg
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24. Cuenca J, García-Erce JA, Muñoz M, Izuel M, Martínez AA, Herrera A. Patients with
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pilot study. Transfusion (Paris). 2004;44(10):1447–52.
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ix–x, 1–210.
26. Warner C. The use of the orthopaedic perioperative autotransfusion (OrthoPAT)
system in total joint replacement surgery. Orthop Nurs Natl Assoc Orthop Nurses
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27. So-Osman C, Nelissen RGHH, Koopman-van Gemert AWMM, Kluyver E, Pöll RG,
Onstenk R, et al. Patient blood management in elective total hip- and knee-replace-
ment surgery (Part 2): A randomized controlled trial on blood salvage as transfusion
alternative using a restrictive transfusion policy in patients with a preoperative hemo-
globin above 13 g/dl. Anesthesiology 2014;23.
28. Park JH, Rasouli MR, Mortazavi SMJ, Tokarski AT, Maltenfort MG, Parvizi J.
Predictors of perioperative blood loss in total joint arthroplasty. J Bone Joint Surg Am
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29. Covert CR, Fox GS. Anaesthesia for hip surgery in the elderly. Can J Anaesth J Can
Anesth 1989;36(3 Pt 1):311–9.
30. Zhang H, Chen J, Chen F, Que W. The effect of tranexamic acid on blood loss and use
of blood products in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol
Arthrosc. 2012;20(9):1742–52.
31. Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA, et al. Anti-
fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane
Database Syst Rev 2011;(3):CD001886.
32. Ryu J, Sakamoto A, Honda T, Saito S. The postoperative drain-clamping method for
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arthroplasty. Bull Hosp Jt Dis N Y N 1997;56(4):251–4.
33. Li Z-J, Fu X, Tian P, Liu W-X, Li Y-M, Zheng Y-F, et al. Fibrin sealant before wound
closure in total knee arthroplasty reduced blood loss: a meta-analysis. Knee Surg Sports
Traumatol Arthrosc 2014.
34. Falez F, Meo A, Panegrossi G, Favetti F, La Cava F, Casella F. Blood loss reduction in
cementless total hip replacement with fibrin spray or bipolar sealer: a randomised con-
trolled trial on ninety five patients. Int Orthop 2013;37(7):1213–7.
35. McConnell JS, Shewale S, Munro NA, Shah K, Deakin AH, Kinninmonth AWG.
Reducing blood loss in primary knee arthroplasty: a prospective randomised controlled
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36. Matziolis D, Perka C, Hube R, Matziolis G. [Influence of tourniquet ischemia on peri-
operative blood loss after total knee arthroplasty]. Orthop 2011;40(2):178–82.

37. Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A
meta-analysis and systematic review. The Knee. 2010;17(2):141–7.
38. Zhang F-J, Xiao Y, Liu Y-B, Tian X, Gao Z-G. Clinical effects of applying a tourniquet
in total knee arthroplasty on blood loss. Chin Med J (Engl) 2010;123(21):3030–3.
39. Keating EM, Meding JB. Perioperative blood management practices in elective ortho-
paedic surgery. J Am Acad Orthop Surg 2002;10(6):393–400.
Chapter 3
Role of Drains in Primary Total

Joint Arthroplasty
INTRODUCTION
The use of drainage systems has a very long history. Hippocrates recom-
mended using a wooden tube to drain the wound after operation.1 The
canon book of Avicenna is probably one of the first written evidence that
mentions the use of drains in the field of orthopaedic surgery.2
It was believed that drains decreased the volume of the haematoma,
and therefore, reduced postoperative swelling, pain and even the rate of
surgical site infection (SSI).3
Waugh and Stinchfield performed a study in 1961 on the advantages
of draining. This study popularized the use of drainage in the field of
orthopaedic surgery. Their study consisted of two groups of matched
patients and the only variable was the usage of drain. They showed that
the duration of postoperative rehabilitation was significantly shorter in
patients with drainage, and the rate of infection was higher in patients
without drainage (this difference was not statistically significant).4
On the other hand, there is mounting evidence to support that closed
suction draining systems can increase the risk of bleeding due to elimi-
nation of the tamponade effect that is created in a closed wound.5–9 The
tamponade effect implies that bleeding continues until the pressure in
the wound increases to a certain level that eliminates further bleeding.
In order to achieve this pressure, enough bleeding is required to fill the
wound space. However, the space of a drainage device is also added to
this dead space. Therefore, more blood is required to achieve this pressure.
Surgeons who support the use of drains tend to use autologous blood
transfusions, fibrin tissue adhesives, local ice packing and compression
bandaging in order to prevent severe blood loss.10–12 However, there is
still controversy concerning drainage use.
The aim of this chapter is to review the current evidence in order to
evaluate the role of drainage systems post total joint arthroplasty (TJA).
POSTOPERATIVE DRAINS IN TOTAL KNEE

ARTHROPLASTY
Use of wound drainage after TJA is a controversial issue. Drain usage has
fluctuated throughout time. Several studies stated that the use of drains
could decrease haematoma formation after surgery.13–15 Some studies pres-
ent that drains can improve wound outcomes in orthopaedic surgery and
can theoretically decrease pain and swelling postoperatively.3,16,17
The size of the haematoma can be evaluated using different techniques.
The easiest way is to compare the pre- and postoperative haematocrit mea-
sures to estimate the hidden blood loss, which would be the haematoma. A
more accurate way to measure the amount of haematoma is by using ultra-
sonography to evaluate the thickness of the blood mass around the implant.
Murphy et al. measured the hidden blood loss in two groups of patients;
one group with drains and the other without them. They found that the
size of the haematoma in the drained group was not smaller. The findings
were justified by the tamponade effect mechanism.18
The most accepted benefit of drains is postoperative wound manage-
ment. Many studies support this statement. Some studies report less accu-
mulation of blood in the wound dressing.3,14,17 Other studies compared the
weight of the discarded dressings of patients with and without drains to
prove this matter.7,19
In support of drainage usage, some studies reported that the area of
ecchymosis is notably less in the drainage group.3,14 Furthermore, forma-
tions of haematoma and effusion were evaluated in a study by Omonbude
et al. using ultrasound 4 days after the procedure, and the results indicated
that the drainage group had less haematoma when compared to the non-
drainage group.20
A survey by Canty et al. presented that the majority of surgeons
believed closed suction drainage can prevent infection.21 However, various
articles have failed to prove the effectiveness of the drains and their role in
infection prevention.3,7,14,17,19,22,23 A meta-analysis by Zhang et al. showed
that infection occurred in 1.2% of the nondrainage group and in 0.5% of
the drainage group; nevertheless, there was no significant difference in the
pooled data.24
One of the most important complications after performing total knee
arthroplasty (TKA) is thromboembolism. It is associated with increased
mortality and morbidity. Currently, there is no consensus among ortho-
paedic surgeons for venous thromboembolic prophylaxis. The protocols
Role of Drains in Primary Total Joint Arthroplasty 31
for prophylaxis vary in different centers. Some surgeons claim performing

TKA using a drain decreases postoperative knee swelling and can also play
a role in thromboembolism risk reduction. However, the literature does not
seem to support this claim. No significant difference was observed when
the incidence of deep vein thrombosis was compared in case-control stud-
ies using drainage systems.5,14,25
The role of drains in the outcomes of TKA has been debated. Several
studies have demonstrated that there is no statistical significance in range
of motion in the absence or presence of a drainage system.5,17,19 We believe
that using a drain cannot improve the range of motion long-term.
As of now, there have been various articles that do not support the use
of a drainage system in TKA.5–9,26–28 These studies juxtaposed the outcomes
of using and not using drainage systems, concluding that not only is the
drainage system not significantly beneficial, but that it can also be harmful.
It has been shown that the risk for blood transfusion is higher when
drainage systems are used.7,17,22 It was also shown that a postoperative drop
in the level of haemoglobin is more severe when drains are used, along with
a longer length of hospital stay.23
Although length of hospital stay depends on various factors, one reason
why patients with drainage have a longer stay is due to the fact that they
refuse to engage in any physical activities while having a drain placed in
their knees, thus delaying their rehabilitation.
In a meta-analysis comparing closed suction drainage and nondrain-
age in TKA, Zhang et al. found no significant difference in the incidence
of infection, deep venous thrombosis and postoperative range of motion
between the two groups.24
USING DRAINS IN TOTAL HIP ARTHROPLASTY

Several studies have evaluated the impact of drains on total hip arthro-
plasty (THA). SSIs are considered the most important complication
related to using drainage systems. Other studies focused on haematoma
size, transfusion rate and hospital stay.
Drains and SSIs

It was believed that drains could decrease the rate of SSI by draining
the haematoma. Willett et al. investigated the relationship between the
duration of drains and wound infection. They recommended that drains
should be removed 24 h after the surgery, as they do not reduce the

size of the haematoma after this period and can even increase the risk
of infection.29
Since then, other studies have supported that the duration of drains
is linked with wound infection. Many agree that the optimal time to
remove the drains after THA is 24 h postoperatively.13,30–32
Size of the Haematoma

In 2002, Widman et al. used an objective method to estimate the hae-
matoma size. They compared two groups of patients; one with two-
drain drainage and the other one without drainage. Using single photon
emission computed tomography, the haematoma size was measured
quantitatively by scintigraphy with labeled erythrocytes. Their study
showed that the haematoma size was not statistically different between
the two groups. Furthermore, patients in the drainage group lost more
blood and had a higher rate of blood transfusion postoperatively.
Authors explained these findings with the tamponade effect.33
Another study by Parrini et al. evaluated the haematoma size in 82
patients after THA using ultrasonography. They compared two groups
of patients with different number of drains; one with two and the other
with only one drain. They found that haematoma was always present
in both groups. Nevertheless, the size of haematoma was significantly
larger in the group where only one drain was applied.34
Postoperative Requirement for Blood Transfusion

The need for blood transfusion is one of the most important evidences
of the theory of the tamponade effect. It is still a controversial issue in
the literature that using drains can increase or decrease the need for
transfusion after surgery. Walmsley et al. investigated the rate of blood
transfusion in a prospective, randomized, controlled trial among 552
patients; their results showed that patients with a drain have a signifi-
cantly higher rate of blood transfusion.35 In another trial by Cheung et
al., it was found that the rate of postoperative blood transfusion is not
significantly different in patients with or without drains.36 Zeng et al.
supported the results of Cheung et al. and concluded that no-drainage
may decrease postoperative blood loss but has no advantage in reducing
the rate of blood transfusion or even deep infection. They also believed
postoperative complications may be higher with no drainage, as early
postoperative exercise can be restricted by pain and swelling.37

On the other hand, a meta-analysis by Parker et al. presented that
closed suction drainage can increase the need for blood transfusion after
TJA and has no significant advantages.8
Length of Hospital Stay

Some surgeons believe that usage of drainage does not directly affect
the length of stay after primary THA.35,38
However, Cheung et al. presented that the wound in patients with
no drains dries significantly sooner (mean 3 days) compared to autolo-
gous blood transfusion drains (mean 4 days) and patients with suction
drains (mean 4 days). They have concluded that patients with no drains
have significantly shorter duration of stay in hospital.36
González Della Valle et al. also showed that length of hospital stay
is longer in patients who underwent elective THA when a drain is
inserted (5.1 days vs. 4.7; p = 0.01). They recommended not using
close-suction drainage in elective THA.39
Borghi and Casati found that there is a link between allogeneic
blood transfusion and the length of hospital stay.40 There is also a rela-
tionship between allogeneic transfusion and disturbances in wound
healing that can also affect the length of hospitalization.41 It can be
concluded that prevention of allogeneic blood transfusion can reduce
the duration of stay, and any matter that increases the risk of allogeneic
blood transfusion can also lead to longer hospitalization.
CONCLUSION
Routine use of drains in the field of orthopaedic surgery has been questioned
recently.
Several randomized trials have been carried out to address this issue.
A recent meta-analysis by Zhou et al. indicated that closed suction drain-
age increases the rate of homologous blood transfusion. They observed no
statistically significant difference in the incidence of blood loss, changes in
haemoglobin level, infection, functional assessment, or other major com-
plications. Their results demonstrated that using closed suction drainage in
elective THA could be even of more harm.42
In conclusion, randomized studies have presented that usage of drainage
is not mandatory in THA and TKA and in some cases could be deleterious.27
In the end, it is surgeon’s judgment, which can identify the patients that
may benefit from insertion of a drainage device.
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autologous transfusion drain or suction drain? A randomised prospective study in total
hip replacement surgery of 168 patients. Acta Orthop Belg 2010;76(5):619–27.
37. Zeng W-N, Zhou K, Zhou Z-K, Shen B, Yang J, Kang P, et al. Comparison between
drainage and non-drainage after total hip arthroplasty in chinese subjects. Orthop Surg
2014;6(1):28–32.
38. Strahovnik A, Fokter SK, Kotnik M. Comparison of drainage techniques on prolonged
serous drainage after total hip arthroplasty. J Arthroplasty 2010;25(2):244–8.
39. González Della Valle A, Slullitel G,Vestri R, Comba F, Buttaro M, Piccaluga F. No need
for routine closed suction drainage in elective arthroplasty of the hip: a prospective
randomized trial in 104 operations. Acta Orthop Scand 2004;75(1):30–3.
40. Borghi B, Casati A. Incidence and risk factors for allogenic blood transfusion during
major joint replacement using an integrated autotransfusion regimen. The Rizzoli
Study Group on Orthopaedic Anaesthesia. Eur J Anaesthesiol 2000;17(7):411–7.
41. Weber EWG, Slappendel R, Prins MH, van der Schaaf DB, Durieux ME, Strümper D.
Perioperative blood transfusions and delayed wound healing after hip replacement sur-
gery: effects on duration of hospitalization. Anesth Analg 2005;100(5):1416–1421, table
of contents.
42. Zhou X, Li J, Xiong Y, Jiang L, Li W, Wu L. Do we really need closed-suction drainage
in total hip arthroplasty? A meta-analysis. Int Orthop 2013;37(11):2109–18.
Chapter 4
Prevention of Periprosthetic
Joint Infection
INTRODUCTION
Total joint arthroplasty (TJA) is one of the most effective medical inter-
ventions and improves the quality of life and function level in most of the
patients suffering from degenerative joint disease. It is predicted that by the
year 2030, the number of primary total knee arthroplasty (TKA) procedures
will reach 3.48 million annually, that is, a 673% increase in comparison to
2005. The demand for primary total hip arthroplasty (THA) is projected to
grow by 174% to 5,72,000, which means that more than 4 million primary
TJAs will be performed in a year just in the United States.1 The number of
revision knee and hip procedures will increase correspondingly.
The average incidence of periprosthetic joint infection (PJI) is between
0.25% and 2.0% within 2 years after primary THA or TKA.2–4 PJI is a seri-
ous complication of TJA; it is the primary indication for revision TKA and
the third indication for revision THA.5–7
Diagnosis of PJI is very challenging because it can present at any time
postoperatively.8,9 Once it is diagnosed, managing PJI is also very difficult.
It requires prolonged rehabilitation, antibiotic therapy and often multiple
procedures to treat.10 It also has a very high and growing impact on the
health care system, with an approximate cost of $320 million for infected
revisions in the United States in 2001 and $566 million in 2009. It is esti-
mated that the cost will exceed $1.62 billion by the year 2020.11
Therefore, strong efforts to effectively treat PJI are mandatory. Treatment
of the infection requires appropriate evaluation of the chronicity and the
causing germ. The wound status and the overall condition of the patient
should also be considered.
In this chapter, we will survey PJI and associated risk factors. Finally, an
overview of the current evidence available for the prevention of PJI will
be provided.
DEFINITION OF PJI
The Musculoskeletal Infection Society has provided a list of criteria based
on the recent available evidence to define PJI. Based on the described cri-
teria, definite PJI exists when12:
A. there is a sinus tract communicating with the prosthesis; or
B. a pathogen is isolated by culture from two or more separate tissues or
fluid samples obtained from the affected prosthetic joint; or
C. when four of the following six criteria exist;
i. elevated serum erythrocyte sedimentation rate and serum C-reactive
protein (CRP) concentration,
ii. elevated synovial white blood cell count,
iii. elevated synovial polymorphonuclear percentage (PMN%),
iv. presence of purulence in the affected joint,
v. isolation of a microorganism in one culture of periprosthetic tissue
or fluid, or
vi. greater than five neutrophils per high-power field in five high-
power fields observed from histologic analysis of periprosthetic
tissue at ×400 magnification.
PJI may still be present if fewer than four of these criteria are met.
Furthermore, in cases infected by low-virulence organisms such as
Propionibacetium acnes, despite the presence of PJI, some of these criteria
may not be usually present.
CLASSIFICATION OF PJI
Depending on the type of pathogenesis or time of clinical diagnosis, there are
different types of classifications of PJI.
When pathogenesis is concerned, two different routes are possible, exog-
enous or haematogenous. Exogenous infections often occur during the sur-
gery or shortly after it, usually when there is a large haematoma. On the other
hand, haematogenous infections can occur at any time postoperatively.13
There are some reports that infected prostheses can impair the immune
system; these reports have also shown that the minimal dose of abscess form-
ing for Staphylococcus aureus has decreased significantly to at least 10,000-fold
in both animal and human models.14,15
Implants could also increase the chance of haematogenous infections;
reports have shown a risk of 30–40% for device-related haematogenous
infection during S. aureus sepsis.16,17
Prevention of Periprosthetic Joint Infection 39
One PJI classification is according to the duration of its clinical mani-

festation postoperatively. This time period is divided into four stages13,18,19:
1. Early postoperative infection occurs within the first 4 to 8 weeks after
the implantation.
2. Delayed-onset PJI presents between the third month up to 24 months
postoperatively.
3. Late-onset PJI usually happens after 2 years from the surgery and often
has a sudden onset in an otherwise well-functioning joint.
4. Silent PJI occurs with the presence of a positive culture at the time of
revision with no previous evidence of infection.
Early, delayed and silent infections usually have exogenous sources.
Early PJIs are often caused by virulent organisms such as S. aureus and
Escherichia coli. On the other hand, delayed and silent are usually caused by
low-virulence microorganisms such as coagulase-negative staphylococci
and Propionibacterium acnes.19,20
As mentioned earlier, late PJI has an acute presentation and is usually
caused by haematogenous spread. The most common source of infection is
known to be skin and soft tissue, but there are some reports of seeding from
respiratory, urinary, gastrointestinal tract and dental infections.21
Sendi et al. reported that the source of infection in 57.5% of haematog-
enous cases of PJI could not be identified, as there was no sign of primary
bacteremia/infection by the time of PJI presentation.16
PREVENTION OF PJI
Development of PJI depends on both host and environmental factors, and
the best way to prevent it is to improve these two factors during the pre-,
intra-, and postoperative phases.
A number of preoperative host factors that can increase the chance
of PJI have recently been identified. These include, but are not limited
to, diabetes, rheumatoid arthritis, congestive heart failure, renal disease,
hypercholesterolaemia, chronic pulmonary disease, venous thromboem-
bolism (VTE), preoperative anaemia, peripheral vascular disease, alcohol
abuse, depression, psychoses, metastatic tumour and valvular disease.4,22,23
Patients who present for elective orthopaedic procedures are typi-
cally in suboptimal health. Furthermore, the impact of various risk fac-
tors appears to be accumulative, such that each factor has an individual
affect to increase the risk of infection and a synergistic potential on the
risk conferred by other factors.24,25 Thus, identifying risk factors and
addressing them in the preoperative setting is critical to reduce PJI and

other postoperative complications.
PREOPERATIVE
Optimization of General Health

Optimizing adjustable health factors such as blood sugar is crucial to ensure a
safe TJA. Reports have shown that the general condition of the patient’s health
has a direct link with the rate of postoperative complications; and conditions
such as ASA >2, uncontrolled diabetes and rheumatoid arthritis can signifi-
cantly increase the risk of PJI.4,22,26–28
As mentioned earlier, some studies presented that medical conditions have
an accumulative effect on the risk of PJI. Lai et al. and Malinzak et al. have
shown that any other medical comorbidity accompanied by diabetes leads to a
higher risk of infection.24,29
Therefore, it is mandatory to assess all patients in a multidisciplinary clinic
prior to TJA and manage comorbidities if required. These assessments have
shown to reduce the postoperative mortality rate and per-admission costs sig-
nificantly in complex orthopaedic surgeries, including TJA.30
Marchant et al. also presented that glycemic control has a high impact on
PJI.31 They found that patients with a higher level of haemoglobin A1c had
significantly higher incidence of PJI, at an odds ratio of 2.31.
Furthermore, Mraovic et al.32 presented that not only is the preoperative
blood glucose level important but the postoperative level also plays an impor-
tant role. Patients with sugar levels greater than 200 mg/dL on postoperative
Day 1 are at a higher risk of developing PJI by twofold.
Therefore, there is a general consensus in the literature supporting the
importance of preoperative health optimization, focusing on the control of
blood glucose level.
Pre-assessment clinics mostly focus on optimizing the host factors in the
preoperative phase (adjustable risk factors) such as nutrition status, blood sugar
level, cardiac and respiratory evaluation, and assessment for possible sources of
infection and Methicillin-resistant S. aureus (MRSA) decolonization.
Bacterial Decolonization
Prevention guidelines regarding surgical site infections (SSIs) published by
the Centers for Disease Control (CDC) have recommended taking a bath
with an antiseptic agent at least once on the night before the operation to
reduce the load of bacteria.33 Many reports have shown that a whole-body
bath with an antiseptic agent reduces the bacterial load in the skin and
lowers the risk of SSIs.34–37 The CDC has also mentioned that SSIs are the
second most common cause of nosocomial infections and are responsible
for more than 25% of hospital-related infections in the United States.38,39
There is still a debate on how to achieve entire body coverage and to
maintain adequate concentrations of the solution for effective results.68
Another issue is the patient’s compliance with these protocols.40
There is some evidence that applying the aforementioned protocol
using chlorhexidine gluconate (CHG) twice daily by patients at home
prior to TJA could significantly reduce the risk of SSIs.41,42 In conclusion,
although home skin preparation before TJA seems to be a simple and cost-
effective technique, patient compliance is still an issue. Future randomized
controlled trials are required to study the effectiveness of these protocols in
the prevention of PJI.
In our institution, patients are required to start using a shower scrub
2 days before the surgery using 4% CHG with 4% isopropyl alcohol
(Hibiclens) once daily.
We do not suggest routine decolonization for nasal MRSA.
Prophylactic Antibiotics
There is mounting evidence in the literature supporting the benefits of
prophylactic antibiotics in the prevention of PJI.43–46 One of the pioneer
studies in the field of orthopaedic surgery is without a doubt that per-
formed by Fogelberg et al. in 1970, where they compared two groups
of patients; one group was given a prophylactic penicillin preoperatively,
intraoperatively and up to 5 days postoperatively; and the other group was
the control with no antibiotics. The incidence of infection was 1.7% in the
treated group versus 8.9% in the control group. The other point mentioned
in this study was the increase in the prevalence of MRSA infections, dem-
onstrating the fine line between the proper use and overuse of antibiotics.43
The aim of prophylactic antibiotics is to cover the spectrum of
the most common organisms of PJI, Staphylococci and Streptococci.
Therefore, cefazolin and cefuroxime are the antibiotics of choice. There
are many debates about the duration of antibiotic coverage in the literature.
Engesaeter et al. have shown that in THA the effectiveness of four doses of
intravenous antibiotics on the operation day is significantly higher than that
for fewer doses. On the other hand, Kasteren et al. have shown that there
is no statistical difference between the single-dose and four-dose regimen.

Furthermore, they found that the rate of aseptic loosening was higher in
patients who received a single-dose regimen.47,48
According to the guideline of the American Academy of Orthopaedic
Surgeons (AAOS), recommendations for the use of intravenous prophylaxis
antibiotics are as follow49:
First, special care is required for selecting the prophylaxis antibiotic,
consistent with the current recommendation of the literature. Patient aller-
gies and resistance issues also need to be taken into account.
Currently, the preferred antibiotics for orthopaedic procedures are
cefazolin and cefuroxime. In patients allergic to ơ-lactam, clindamycin and
vancomycin are good substitutions. Vancomycin is also recommended for
patients with known MRSA colonization or in centers with recent MRSA
outbreaks.
There is always a risk of colonization and infection development of
VRE due to exposure to vancomycin. An excessive use of vancomycin is
strongly discouraged. It should be reserved for serious ơ-lactam-resistant
infections or in patients with allergy to ơ-lactam antimicrobial agents.
Second, the efficiency of the therapy depends on the timing and dose
adjustment of antibiotics. The best time for administration of prophylactic
antibiotics is within 1 h before skin incision. For antibiotics with longer
infusion time such as vancomycin, this time period should be extended to
2 h. In case of tourniquet use, the antibiotic must be fully infused prior to
tourniquet inflation.
Dose adjustment of the antibiotics is also a very important issue and
there are some circumstances in which the dose should be increased:
1. Antibiotic dosage should correspond with the patient’s weight; for
example, in patients heavier than 80 kg, the dose of cefazolin should be
doubled.
2. If the surgical duration lasts one to two times longer than the half-life
of the administered antibiotic.
3. In cases of significant blood loss.
The guideline for intraoperative administration of antibiotics is: every
2–5 h for cefazolin, every 3–4 h for cefuroxime, every 3–6 h for clindamy-
cin and every 6–12 hours for vancomycin.
Third, postoperatively, the administration duration of the prophylactic
antibiotics should not be more than 24 h. There is no evidence in the lit-
erature to support the benefit of continuing prophylactic antibiotics after
drains or catheters are removed after 24 h postoperatively.
Indications for Vancomycin

For the majority of patients who undergo elective arthroplasty, first-
generation cephalosporins are sufficient. However, vancomycin might be
needed for some patients. In our opinion, patients with the following
criteria are required to have vancomycin in addition to a first-generation
cephalosporin:
1. Known carriers of MRSA.
2. Patients from dialysis units, nursing homes, or centers with confirmed
outbreak of MRSA.
3. Health care workers.
4. Patients with a history of penicillin allergy. While clindamycin is a well-
known alternative for these patients, because of the high association of
Clostridium difficile enteritis and clindamycin consumption, it is highly
recommended to use vancomycin.50
There are two important points that should be considered when van-
comycin is prescribed: first, vancomycin must be administered with slow
infusion (at least 1 h) to prevent adverse effects such as hypotension, chest
pain and red man syndrome.51
Second, vancomycin does not have full coverage on methicillin-sensi-
tive S. aureus. Therefore, it should always be administered in combination
with a cephalosporin.52
The current practice at the Rothman Institute for administration of
prophylactic antibiotics is as follows:
1. Approximately 30 min before the surgery, cefazoline is given to all
patients.
2. In patients with a positive history of MRSA or allergy to penicillin,
vancomycin is infused 60 min previous to the skin incision.
3. All prophylactic antibiotics are discontinued 24 h postoperatively.
INTRAOPERATIVE
Preoperative Hair Removal

Although hair removal at the incision site is part of the routine preparation
for surgery, there is no evidence to support that this practice can decrease
the risk of SSIs.
Furthermore, there are some reports showing that hair removal could
even be harmful and increase the risk of infection. A review article pub-
lished by the Cochrane group concluded that there was no statistical differ-
ence in the rate of SSIs between operations where patients had hair removal
and those in which hair was not removed. The study also mentioned that
there was a significantly higher rate of SSIs among patients having hair
removal with a razor than those whose hair was removed with clippers.53
Preoperative Skin Preparation
Patients
Native microorganisms of the skin have always played an important role
in SSIs. Von Eiff et al. have presented that the cause of more than 80% of
hospital-acquired S. aureus infections is endogenous bacteria, which colo-
nize in the patient’s epidermis, according to genotyping studies.54
According to the estimation of the CDC, the SSIs are the second major
cause for nosocomial infections, which are responsible for more than one-
fourth of the health care related infections in the United States.38,39
Orthopaedic surgery is not exceptional and many SSIs in this field are
acquired during the surgery, with the main source being skin flora.55,56
Regardless of the recent advances in prophylactic antibiotics, the impor-
tance of skin decolonization agents is more prominent than ever before.57
There are many kinds of antiseptic agents available for skin prepara-
tion before surgery. The three agents most commonly used are CHG,
alcohol-based solutions, and povidone-iodine. Each of them has some
advantages and some disadvantages. Chlorohexidine, for instance, is very
popular due to long-lasting, accumulative effect against gram-positive and
gram-negative bacteria commonly found in human skin flora. On the
other hand, povidone-iodine is very effective on skin flora but becomes
relatively ineffective upon contact with blood and has shorter duration
of activity than CHG.
Alcohol is a very good antimicrobial agent but the flammability and
discontinued effects after drying are the downsides of this agent. A meta-
analysis published by Cochrane group in 2004 presented that there is no
significant difference in the rate of SSIs in clean surgeries carried out with
different antiseptic agents for the skin preparation.57
More recent studies have mentioned that the combination of alcohol
and CHG is more successful than alcohol and povidone-iodine in reduc-
ing the bacterial load of the skin; however, the rate of SSIs is not signifi-
cantly different.58–60
Surgeon
There are two main types of hand antiseptic agents for hand prepara-
tion: hand scrub solutions and hand rub agents. Usually hand scrubs are
solutions of CHG or povidone-iodine and hand rubs are mostly alcohol-
based solutions.
Most of the studies in the literature claim that the efficacy of povidone-
iodine and CGH are the same in decreasing bacterial colony units, and the
rate of SSIs was not different in using either hand scrub solutions or hand
rubs.61,62 In addition to being cost-effective, some reports mentioned that
hand rubs reduce water consumption and increase surgeon compliance.61
Draping
There are numerous articles supporting the use of plastic surgical adhesive
tapes or non-permeable paper drapes for draping the surgical site.63–66
Traditional cloth drapes tend to get wet during the surgery and could
increase bacterial penetration; nonpermeable paper drapes were introduced
to overcome this issue.63 Ritter et al. have presented that Ioban iodophor-
impregnated drapes (3M Health Care) can reduce wound contamination
but do not decrease the wound infection rate after TJA.67
In a microbial evaluation study of adhesive plastic surgical drapes, deep
wound contamination was compared between plastic adhesive drapes and
cloth drapes. The cultures were collected right before the closing and the
result showed 60% of contamination when cloth drapes were used vs. 6%
contamination with plastic adhesive drapes.63
In another study performed by Fairclough et al., it was reported that
the rate of wound contamination during hip surgery decreased from 15%
to 1.6% after using plastic adhesive drapes.68
The efficacy of plastic adhesive drapes is optimum when the skin prepa-
ration is performed using alcohol-based solutions. DuraPrep is considered
to improve the adhesion properties of the drapes, and it is hypothesized to
decrease wound contamination.69
Plastic adhesive drapes can provide a sterile operative field at the begin-
ning of the surgery and by immobilization of the bacteria underneath the
drape; the risk of surgical site contamination is also reduced. Furthermore,
iodophor-impregnated drapes also apply antimicrobial protection to the
skin and can reduce the risk of contamination.
However, there are controversies about the effectiveness of plastic
adhesive drapes in the prevention of bacterial contamination. In 2007, the
Cochrane Wound Group reviewed 4000 patients in seven different studies
and concluded that there is no positive evidence for the reduction of the
rate of SSI by using adhesive drapes (plain or infused with antimicrobials).70
Gloving
Sterile surgical gloves are dual protection barriers; on one hand, they pro-
tect the patients from residual bacteria on the surgeon’s hands, and on the
other hand, they protect the surgeon from the patient’s body fluids.
Because double-gloving reduces the risk of perforation, it is highly rec-
ommended for orthopaedic procedures, where sharp edges are commonly
encountered during the surgery.71–73 In a study, Beldame et al. presented
that changing the exterior glove after the incision and prior to the implan-
tation can reduce the risk of perforation by 80%.74
Furthermore, some studies have shown that even double-gloving is
not enough and inner gloves could have perforations and contamination.
Accordingly, triple-gloving has been recommended during TJA to prevent
the risk of contamination and PJI.75,76
The triple-gloving protocol was introduced by Sutton et al. in 1998.
The protocol was to use two latex gloves with a cut-resistant layer between
them. Results showed a meaningful decrease in the incidence of perfora-
tion in comparison with the double-gloving protocol. Triple-gloving is
also very popular in maxillofacial surgeries.77 In a study by Pieper et al.,
different protocols of triple-gloving were compared with double gloving
in maxillofacial surgeries. The study showed that all different techniques of
triple-gloving are superior to double-gloving in terms of inner glove perfo-
ration. However, triple-gloving has some disadvantages, such as a decrease
in tactile sensation and surgical dexterity.78
Operating Room Environment
Laminar Flow
The main goal in designing the operating room (OR) is to reduce patient’s
exposure to bacteria during surgery. Laminar airflow (LAF) was first intro-
duced in the United States in 1964. Positive air pressure is created in the surgi-
cal field via the directional airflow passing through higher-efficiency particulate
air by vertical LAF and can help to reduce the incidence of PJI.79–82 However,
Brandt et al. state that LAF provides no benefits and even increases the risk of
SSI after THA. Eight studies conducted over a span of 10 years were pooled
in a recent systematic review, which concluded that LAF does not reduce the
rates of PJI; therefore, the authors did not recommend its installation in ORs.83
The LAF is often disrupted by the opening of the OR door, therefore

giving pathogens an opportunity to enter the area around the operation
site and increasing the risk of PJI.67,79,84 The average rate of door open-
ings for primary and revision TJA has been reported by Panahi et al. to be
0.69 openings per min and 0.84 openings per min, respectively. Despite
frequent traffic entering and exiting the OR, it is recorded that only 8%
corresponds with scrubbing in and out, showing a high amount of unjusti-
fied traffic during the operation. Therefore, it is recommended to try and
decrease traffic in the OR in order to reduce the risk of PJI.85 On the
other hand, there is mounting evidence supporting that LAF can decrease
the incidence of SSIs and the bacterial count in the surgical site and on
instruments.79,86–91
In 1982, Lidwell et al. presented that there was a direct relationship
between the number of airborne organisms and the rate of deep postopera-
tive infections. The authors showed that the incidence of SSIs had decreased
from 3.4% to 1.6% by adding LAF systems to the ORs. Nevertheless, there
is still controversy about the pros and cons of LAF.92
The CDC has no comment supporting whether LAF may reduce the
rate of SSI. There is no specific suggestion for performing arthroplasty
procedures under LAF. Nonetheless, the CDC has published the following
guidelines:
CDC Guidelines:93
1. Maintain positive-pressure ventilation with respect to corridors and
adjacent areas.
2. Maintain *15 ACH, of which *3 ACH should be fresh air.
3. Filter all recirculated and fresh air through the appropriate filters, pro-
viding 90% efficiency (dust-spot testing) at a minimum.
4. In rooms not engineered for horizontal LAF, introduce air at the ceiling
and exhaust air near the floor.
5. Do not use ultraviolet lights to prevent SSIs.
6. Keep OR doors closed except for the passage of equipment, personnel
and patients, and limit entry to essential personnel.
Personal Protection Systems

In the 1960s, Sir John Charnley was the first to introduce the idea of the
personal protection system (PPS), also known as the human exhaust system,
in order to decrease the number of airborne bacteria and contamination in
TJA.94 There is no uniform opinion regarding the use of PPS in relation
to the incidence of PJI.95–98 Major issues to consider regarding PPSs are
their bulkiness and susceptibility to contamination. Kearns et al. reported

in a current study that out of 102 PPSs that were tested, 53 were contami-
nated with Staphylococcus and one was contaminated with MRSA. They
concluded that in more than half of the cases, the PPS does not stay sterile
externally. It was advised that the PPSs not be touched during procedures,
and if contact does occur, the gloves should be replaced.99
OR Traffic
Contamination rates have a direct association with OR traffic. Some stud-
ies have shown that the major cause of OR contamination is OR staff.
Furthermore, more staff leads to more door openings, which can interfere with
LAF and cause turbulence, which itself can increase the rate of infection.87,100,101
In a study performed by Panahi et al., it was shown that the average
door openings is 0.65 per min during the course of a primary arthroplasty
and this rate is 0.84 per min for revision cases. Among these door open-
ings, 35% occurred before the incision. Most of the door openings were
created by circulating nurses and equipment company representatives. In
47% of cases, the people who entered the OR had no identified reason for
entering the room. The study concluded that the majority of OR traffic
could easily be eliminated.85 Another disadvantage of increased OR traffic
is the distraction it causes for the surgeon.101
The CDC recommendation for OR traffic is to ‘keep OR doors closed
except for the passage of equipment, personnel and patients, and limit entry
to essential personnel.’93
Operative Time
The risk of PJI after TJA has been stated to increase after extensive opera-
tive times.102–104 After observing 9245 patients undergoing TJA, it was
concluded by Pulido et al.4 that longer operation hours are mainly respon-
sible for PJI. Kurtz et al. and Peersman et al. support this conclusion.105,106
The rate of PJI tends to be inversely proportional to the surgeon’s volume,
meaning that the lower the surgeon volume, the higher the risk of infec-
tion. This seems to be especially statistically significant after TKA.107
Addition of Antibiotics to Cement

As of now, the use of antibiotic-impregnated cement is the standard for use
when performing cemented primary arthroplasty. When both intravenous
antibiotic prophylaxis along with antibiotic-impregnated cement is used in
procedures, the risk of PJI tends to be lower.27,47
Antibiotic-impregnated cement is particularly used in revision set-

tings.108–110 When juxtaposing the effects of solely using prophylactic anti-
biotics against its combination with cement-impregnated antibiotics, it is
evident that the combination of the two is much more efficient for patients
possessing other PJI risk factors.111,112
Polymethyl methacrylate (PMMA), more routinely called bone
cement, is an effective method for topical delivery of antibiotics in the
bone and joint.113 However, not all antibiotics are compatible for use with
PMMA. In order to be suitable, the antibiotic should meet the following
criteria114:
1. Tolerance to high temperature caused by exothermic reaction in the
cement.
2. Diffusible in water.
3. Ability to be combined with other antibiotics.
4. Have low allergic potential.
5. Preferably have a long half-life.
Wound Closure and Surgical Dressing

Numerous techniques such as skin staples, absorbable sutures and knotless
barbed sutures are used for skin closure in arthroplasty procedures. It has
been concluded in a recent study by Smith et al. that compared to tradi-
tional suturing, skin staples increase the risk of infection when closing the
wound. However, only one among six reviewed studies possessed accept-
able methodology.115 In a study performed by Newman et al. observing
181 patients after TKA, it was reported that there were far fewer complica-
tions when using skin staples for wound closure when paralleled with the
absorbable subcuticular sutures method.116
A randomized control study was conducted by Eggers et al. in order
to record the superficial infection rates of subcuticular sutures and tissue
adhesives and skin staples after TKA. The results indicated that subcu-
ticular sutures had the highest rate of infection (26%) and skin staples had
the lowest (5%); yet neither technique needed any antibiotic treatment.
Additionally, the skin staple method was not only quicker but also the most
cost-efficient. However, it required the patient to have a longer hospital stay
compared to other techniques.117
Knotless barbed sutures have recently been a topic of high interest in
wound closure techniques after TJA. The majority of studies done on this
method have reported that barbed sutures have a quicker closure time
when juxtaposed with traditional techniques.118–120
In another study done by Patel et al., it was reported that using barbed
sutures could cause a higher chance of wound complications particularly after
TKA (4.3%) as opposed to staples (1.1%) and standard absorbable method
risks (4.2%).118 Nevertheless, there are still disputes regarding the ideal closure
technique. Cautious tissue handling and the kind of dressing applied after the
procedure are essential factors in the wound healing process and influence
the surgical method performed.121,122 The role of the wound dressing is to
act as a barrier between the tissue and the external bacteria, preventing the
wound from possible injuries. It also assists with homeostasis and reduces
dead space and discomfort. Furthermore, re-epithelization and collagen syn-
thesis rates are increased in wounds that have the wound dressing applied to
them when compared to wounds that are allowed to be exposed to air.123,124
Dumville et al. conducted a recent Cochrane review comparing dif-
ferent dressings and found that there is no evidence to support that one
dressing is more ideal than the other for preventing SSIs. The review sug-
gests the decision of choosing a dressing should be based on the cost and
necessity of the product.125
Using the jubilee technique, a hydrofiber/hydrocolloid dressing has been
observed to reduce blister formation rates after TJA, but has no particular
effect on the rate of SSIs.121
A prospective randomized study performed by Burke et al. paralleling
standard adhesive dressing and the jubilee method after TJA recorded a
noteworthy decrease in leakage and blister formation with the jubilee dress-
ing technique; however, no significant decrease in the SSI rate was observed.
Therefore, the authors suggest using the hydrofiber/hydrocolloid dressing
technique in order to reduce possible complications after TJA.126
POSTOPERATIVE
Postarthroplasty Antibiotic Prophylaxis

As mentioned earlier, PJI can occur any time after the surgery. Episodic
bacteremia could be a potential risk for PJI and certain medical procedures
are more likely to cause bacteremia. Therefore, in 2012, the AAOS released
a new guideline on ‘The Prevention of Orthopaedic Implant Infections
in Patients Undergoing Dental Procedures.’ The guideline is a production
of teamwork between the AAOS and the American Dental Association
(ADA). It has three main recommendations127:
1. The practitioner might consider discontinuing the practice of routinely

prescribing prophylactic antibiotics for patients with hip and knee pros-
thetic joint implants undergoing dental procedures.
2. We are unable to recommend for or against the use of topical oral
antimicrobials in patients with prosthetic joint implants or other ortho-
paedic implants undergoing dental procedures.
3. In the absence of reliable evidence linking poor oral health to prosthetic
joint infection, it is the opinion of the work group that patients with
prosthetic joint implants or other orthopaedic implants maintain appro-
priate oral hygiene.
Although the first recommendation is supported by limited documenta-
tion, it has the highest level of evidence. The second is an inclusive recom-
mendation; according to the current literature, the benefits of topical oral
antimicrobials are not quite clear. The third recommendation is a consensus.
In August 2013, 400 delegates from 52 countries and 130 professional
societies gathered together, forming 15 different workgroups to discuss rec-
ommendations and convening again to form a consensus on the practices
of treating PJI. The meeting resulted in a book, which discusses almost all
of the critical and debateable points of PJI.
The workgroup concluded that the use of prophylactic antibiotics prior
to dental procedures in patients who underwent TJA should be based on
individual patient risk factors and the complexity of the dental procedure.
Furthermore, in cases of viral infection, it is recommended that there is
no role for oral antibiotics, even for patients at higher risk.
The workgroup also concluded that for other minor surgical proce-
dures such as endoscopy and colonoscopy, transient bacteremia could be
minimized by administration of prophylactic antibiotics, especially in high-
risk patients.128
CONCLUSION
PJI infection is a serious complication with significant morbidity and
mortality. Several factors in the pre-, intra- and postoperative phases are
involved that can predispose a patient to PJI. It is always better to focus on
prevention rather than treatment. One of the most important preoperative
factors to reduce the risk of PJI is optimization of the patient’s health. It is
recommended to have all patients evaluated in pre-assessment clinics prior
to elective TJA. Administration of preoperative prophylactic antibiotics
should always be considered. It is crucial to follow the recommendations

of the CDC and AAOS to minimize the risk of infection intraoperatively.
Finally, patients who undergo TJA are always at risk of infection; therefore,
it is very important to prescribe prophylactic antibiotics prior to certain
medical procedures.
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clinical audit of a new dressing design for lower limb arthroplasty wounds. J Wound
Care. 2009;18(1):5–8, 10–1.
122. Cosker T, Elsayed S, Gupta S, Mendonca AD, Tayton KJJ. Choice of dressing has a
major impact on blistering and healing outcomes in orthopaedic patients. J Wound
Care 2005;14(1):27–9.
123. Cho CY, Lo JS. Dressing the part. Dermatol Clin 1998;16(1):25–47.
124. Mertz PM, Marshall DA, Eaglstein WH. Occlusive wound dressings to prevent bacte-
rial invasion and wound infection. J Am Acad Dermatol 1985;12(4):662–8.
125. Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical
site infection. Cochrane Database Syst Rev 2011;(7):CD003091.
126. Burke NG, Green C, McHugh G, McGolderick N, Kilcoyne C, Kenny P. A prospec-
tive randomised study comparing the jubilee dressing method to a standard adhesive
dressing for total hip and knee replacements. J Tissue Viability 2012;21(3):84–7.
127. Gross L. AAOS, ADA Release CPG for Prophylactic Antibiotics. AAOS website.
Available at: http://www.aaos.org/news/aaosnow/jan13/cover1.asp. Last updated
December 7, 2012. Last accessed April 9, 2014.
128. Chen A, Haddad F, Lachiewicz P, Bolognesi M, Cortes LE, Franceschini M, et al.
Prevention of late PJI. J Arthroplasty 2014;29(2 Suppl):119–28.
Chapter 5
Pain Management in Arthroplasty

Shubhranshu S. Mohanty, Kumar Kaushik Dash
INTRODUCTION
While pain after arthroplasty involves both acute perioperative pain, and
chronic/late-onset pain, the latter is beyond the scope of this chapter (and
perhaps best studied along with complications of arthroplasty). The fol-
lowing section will describe pain in general, along with the pain pathway,
followed by different modalities available for pain relief in general, and
ultimately, the chapter will end with algorithm of multimodal pain man-
agement specific to the arthroplasty scenario.
WHAT IS PAIN?
Pain is designed as a protective mechanism in a living organism to detect
potential or actual tissue-damaging processes and to maintain homeostasis.1
In addition to the sensation of stabbing/burning/tearing, etc., pain usually
also has associated emotional and behavioral responses in the form of fear,
nausea, increased pulse and blood pressure.1 Often, local muscle contraction
(e.g., limb flexion) is also present.1
PAIN PATHWAY
Pain pathway involves a peripheral and a central component, starting from
pain receptors at periphery, going up till thalamus and cerebral cortex cen-
trally (see Fig. 5.1).
Peripheral nerves contain motor, sensory and autonomic (e.g., sympathet-
ic) fibers.The cell bodies of primary afferent neurons reside in dorsal root gan-
glion. Their axon divides into two branches, with one projecting peripherally
and the other centrally into the spinal cord (Fig. 5.2). These sensory primary
afferents are classified according to their diameter, myelination and conduction
velocity. Small-diameter myelinated A-ƣ and unmyelinated C axons conduct
pain sensation, and their nerve endings respond maximally only to painful/
noxious stimuli.These are known as the primary afferent nociceptors. The noxious
Pain Pain Pain Pain

receptor receptor receptor receptor
Primary Primary Primary Primary

afferent afferent afferent afferent
axon axon axon axon
(Type A (Type C) (Type A (Type C)
Delta) Delta)
Here, each axon
terminal activates
multiple spinal
neurons and each
spinal neuron
is activated by
multiple axon
Spinal Spinal Spinal Spinal terminals.
neurons in neurons in neurons in neurons in
dorsal dorsal dorsal dorsal
horn grey horn grey horn grey horn grey
matter matter matter matter
Spinothalamic
tract
(contralateral)
Thalamus
T ic
pro halam alam
jec
t ic Th ection
cor ion t j
pro cortex
tex o
to
Insular &
Somatosensory cingulate
Cortex Cortex
Fig. 5.1 The pain pathway.

Pain Management in Arthroplasty 61
Synapse at
Dorsal root dorsal
ganglion grey horn
Ventral
grey horn
Lateral
spinothalamic
tract
Fig. 5.2 Arrangement in spinal cord.
stimuli include heat, intense cold, intense mechanical stimuli, acidic environ-
ment and certain chemicals (ATP, serotonin, bradykinin, histamine).
Terminals of primary afferent axons end at dorsal horn of spinal grey
matter by synapsing with spinal neurons of central pain pathway. Each axon
terminal activates multiple spinal neurons, and each spinal neuron is activat-
ed by multiple axon terminals. Axons from most of the spinal neurons cross
to opposite side and ascend to thalamus as the contralateral spinothalamic
tract. Pain signal travels from thalamus to different areas of cortex through
thalamo-cortical projections. Thalamic projection to the somatosensory
cortex provides the perception of sensory aspect of pain. The emotional
perception and response to pain involves the thalamic projection to cingu-
late gyrus and insular cortex in the frontal lobe.
FACTORS AFFECTING TRANSMISSION AND

PERCEPTION OF PAIN
Sensitization
Sensitization refers to the phenomenon where the threshold for activation
of pain receptors is lower and the frequency of firing is higher for all stimu-
lus intensities.1 This can occur both at the level of peripheral nerve endings
(peripheral sensitization) and at dorsal horn of spinal cord (central sensitization).

Deep tissues, e.g., joints, which are usually relatively insensitive to noxious
stimuli, become extremely sensitive after sensitization during inflammation
and postsurgical period. Central sensitization has been proven to play an
important role in painful knee osteoarthritis.2
Nociceptor-induced Inflammation
Primary afferent nociceptors do not function as simple passive pathways for
pain conduction. When activated, they release polypeptide mediators (e.g.,
substance P), and cause local inflammation. Targeting pain control before
anticipated event (e.g., surgery) may minimize this.
Referred Pain (Convergence-Projection Hypotheses)

Visceral primary afferent fibers carrying the pain sensation converge on
same pain-projection neurons as the fibers from somatic structures. This
leads to mistaken projection of pain to the somatic structure by the brain.
Pain Modulation
Patients who have more pain catastrophizing preoperatively have more pain
after surgery.3 Furthermore, patients with low preoperative mental health have
more pain and worse functioning lasting longer after total knee arthroplasty
(TKA). Similar intensity and type of stimuli can produce variable perception
of pain in different scenarios. Expectation of pain can induce pain even with-
out any noxious stimulus.1 While the ascending pathway carries pain sensation
from the site of stimulus to the brain, neurogenic circuits from hypothalamus,
midbrain and medulla control and modulate the spinal transmission neurons
through a descending pathway. This forms the basis of how pain perception
is affected by expectation, behavioral changes and psychological variables.
Endogenous opioids (e.g., enkephalins, ơ-endorphin) provide pain relief
through this pain modulating circuit. Both pain-inhibiting and pain-facilitating
neurons form the parts of this circuit. Hence, the role of suggestion, attention,
expectation and other psychological factors is important in pain perception.
MODALITIES OF TREATMENT
Cyclooxygenase Inhibitors
Aspirin, acetaminophen (paracetamol) and other nonsteroidal anti-
inflammatory drugs inhibit cyclooxygenase (COX), producing analgesic

and anti-inflammatory effects.
The most common side effect is gastric irritation. Aspirin addition-
ally increases the risk of gastro-intestinal bleeding by irreversibly acetylating
platelet COX. Nephrotoxicity, although rare, must be kept in mind in old
dehydrated patients; patients with heart failure, liver cirrhosis, and long-
term diuretic use; or during acute volume depletion (e.g., blood loss during
surgery).4 Parenteral ketorolac is potent and rapid acting enough to replace
opioids for many patients. COX-2 selective inhibitors (e.g., celecoxib) are
beneficial in post-surgical environment because they do not affect blood
coagulation and produce less gastric irritation. However, they do not lower
the risk of nephrotoxicity. Due to increased cardiovascular risk, they should
be used with caution in patients with cardiac disease or cardiac risk factors.
Celecoxib is currently the only COX-2 inhibitor available in the United
States.4 It is possible that increased cardiovascular risk is a class effect of all
nonsteroidal anti-inflammatory drugs (NSAIDs) except aspirin.1 Etoricoxib,
although being used in many countries, is yet to gain FDA (US) approval.
Opioid Analgesics
Opioid analgesics are the most potent, reliable and effective methods for rapid
pain relief. The common but reversible side effects are nausea, vomiting, con-
stipation and pruritus. Recently, peripherally acting opioid antagonists (e.g.,
alvimopan, methylnaltrexone) have become available for treating opioid-
induced side effects. The most serious side effect is respiratory depression;
hence, patients with respiratory illnesses must be kept under close observa-
tion during opioid administration. Opioids produce pain relied by acting on
pain-inhibitory neurons and pain-transmission neurons, probably through
the opioid receptor (μ-receptor). The effects are dose-related, and the dose
for pain relief and side effects varies greatly among patients. The most com-
mon error made by physicians in managing severe pain with opioids is to
prescribe an inadequate dose. This can be attributed to the exaggerated fear
of addiction and possibly other side effects such as respiratory depression.
An interesting way to achieve adequate pain relief in such a scenario
is the use of patient controlled analgesia (PCA). In this method, a micro-
processor-controlled infusion device administers a pre-programmed dose
of an opioid drug, which is titrated to the optimum level by the patient.
To prevent overdosing and its side effects, there is a provision for lockout
period after each demand dose and a limit on total dose of opioid deliv-
ered in an hour.
Another way to maximize pain relief without increasing side effects

involves administering opioids directly to the spinal or epidural space. This
is particularly beneficial in postoperative scenarios. The dose of morphine
required when used intrathecally is less than a tenth of dose required when
administered intravenously.
Combination of Opioid and COX Inhibitors

The analgesic effect of opioids and COX inhibitors is additive when used
simultaneously, while the side effects are non-additive. This allows effective
pain relief without any significant side effects. However, fixed ratio com-
binations of opioid and acetaminophen (paracetamol) may lead to hepato-
toxicity during dose escalation (due to acetaminophen).
Other Analgesics (Antidepressants and Antiepileptics)

Tricyclic antidepressants (TCA) produce analgesic effects at a lower dose
and shorter time than their antidepressant effect. They potentiate opioid
analgesia and are most effective in neuropathic pain. The significant side
effects include orthostatic hypotension, cardiac conduction delay, memory
impairment and drowsiness. Selective serotonin reuptake inhibitors (SSRI)
have less serious side effects but their analgesic efficacy is also lower.
Venlafaxine and duloxetine (serotonin norepinephrine reuptake inhibitors,
SNRI) provide pain relief similar to that of TCAs with fewer side effects.
Newer anticonvulsants such as gabapentin and pregabalin have good anal-
gesic efficacy and a favorable side effect profile. Randomized trials of their
use in total joint arthroplasties have shown decreased narcotic use and less
chance of future neuropathic pain, although increased sedation and confu-
sion particularly with pregabalin.5,6
Neuraxial Anaesthesia
Spinal and epidural anaesthesias usually involve injection of a local anaes-
thetic in to the intrathecal or epidural space for pain control during surgical
procedures. Addition of morphine improves the pain relief and decreases
the usage of intravenous opioids required post-op. Addition of epinephrine
increases local concentration of local anaesthetic by causing vasoconstric-
tion. Epidural anaesthesia is further helpful by providing effective pain
control during the post-operative period. Also, the side effects of opioid
(nausea, vomiting, pruritus) are comparatively fewer in this when compared
with parenteral route.
Peripheral Nerve Block

Urinary retention and hypotension are two unpleasant problems seen with
continuous epidural anaesthesia. Peripheral nerve blocks provide similar
level of pain relief without these problems. Under the guidance of ultra-
sound or nerve stimulator, local anaesthetic is injected around peripheral
nerves. Femoral and sciatic nerves are targeted in TKA; with lumbar plexus
being the target in total hip arthroplasty (THA). Block can be administered
as a one-time injection or as continuous release catheter. Long acting local
anaesthetics (e.g., bupivacaine) and adjuvants (e.g., epinephrine, steroids)
prolong the pain control. Catheter method provides better pain control,
but has 0–3% risk of infection and 0.2% risk of nerve injury. Peripheral
nerve blocks should ideally be done in a separate designated block room
to increase efficiency and allow adequate time for onset of analgesia.4 The
procedure usually takes less than 15 min to perform.
Periarticular Injections
There have been multiple well-designed studies on injection of local anaes-
thetic alone or local anaesthetic (bupivacaine/ropivacaine) plus epinephrine/
morphine/ketorolac (multidrug injections) within and around the joint
intraoperatively, with conflicting results. The protocols vary according to
dose, composition, location and presence/absence of catheter. ROC cocktail
is one of the commonly described combinations; consisting of 0.5% bupi-
vacaine (200–400 mg), morphine sulphate (4–10 mg), 1:1000 epinephrine
(300 mcg), methylprednisolone acetate (40 mg) and cefuroxime (750 mg) in
normal saline.7 Vancomycin is to be used instead if patient is allergic to peni-
cillin. Steroids are avoided in diabetics and immunocompromised patients.
The benefits include better pain relief, decreased narcotic consumption, and
in some trials, better patient satisfaction. Because of heterogeneity of results,
critical appraisal of individual protocol by the surgeon is important before
incorporating this modality as a part of the pain management strategy.
PAIN IN ARTHROPLASTY AND ITS MULTIMODAL

MANAGEMENT
Historically, pain after joint replacement has often been inadequately man-
aged.8 The problems of uncontrolled pain include patient discomfort, slow/
delayed rehabilitation, prolonged hospital stay, unplanned readmissions, higher
health care cost, perioperative medical complications and eventually, com-
promised ultimate function and patient dissatisfaction.4,9 Traditionally, high

dose intravenous opioids have been used in the form of PCA. However,
this has led to the problems of delayed recovery, and has increased length
of stay. Also, in patients who are desensitized and tolerant to opioids, pain
control becomes difficult.
Multimodal pain management was devised by Kehlet and Dahl10 and
Wall11 to address these problems. It uses the principle of targeting different
sites of pain pathway with multiple agents acting synergistically, requir-
ing lower dose of each drug. It achieves more efficient pain control while
decreasing the incidence of side effects at the same time. Pain is addressed
pre-emptively to prevent the beginning of a cycle of pain4 and to limit
sensitization of the nervous system.12
The comprehensive multimodal management algorithm involves the
following components.
1. Pre-emptive analgesia with preoperative medications.
2. Neuraxial anaesthesia.
3. Regional nerve blocks or periarticular injection.
4. Postoperative oral and intravenous medications.
There have been multiple comparative studies to assess the benefits of mul-
timodal pain management. Few important ones are mentioned in Table 5.1.
Choosing a protocol for multimodal pain management should take
into the consideration the above-mentioned principles and components.
Institutes should be able to develop their own protocol that gradually
evolves over time with inputs from past experience and available inventory.
Few important points to remember are listed below.4,9
1. Tolerance to opioids: A thorough pre-op assessment is essential in
patients who are on opioid analgesics for chronic pain. Such patients may
not get adequate pain control with the standard protocol. Consideration
should be given to weaning these patients off the opioids before surgery
and/or involving a dedicated pain management specialist in the team.
2. Patient expectations: Unrealistic expectation of the patient may lead
to decreased satisfaction and more perception of pain. Patient assessment,
counseling and education are essential before surgery.
3. Pre-op cocktail: Pre-emptive does not mean only before incision, but
also implies adequate magnitude and time.12 Oral analgesic cocktail should
be given to the patient with one sip of water 1 h prior to surgery. This
ensures therapeutic plasma levels of analgesics at the time of the end of the
surgery. (see Table 5.2 for details)
4. Neuraxial anaesthesia: Unless contraindicated, spinal anaesthesia
Table 5.1 Evidence for multimodal strategy
Study Design Details of multimodal Advantage of

regimen multimodal strategy
Peter Two retrospective Oral narcotics, Less narcotic consu-
et al.13 cohorts of 50 TJA COX-2 inhibitors, mption, better pain
patients, before and femoral nerve catheters control and walking
after introduction and periarticular distance.
of multimodal injections No change in
protocol complications.
Fu RCT, 100 TKA Oral celecoxib and Less narcotic consump-
et al.14 patients, multimodal tramadol before and tion, lower VAS
vs. placebo after surgery; intra- scores, earlier achieve-
articular injection of ment of physiotherapy
morphine, ropivacaine, milestones. Apart from
epinephrine decreased nausea and
and betamethasone vomiting, other com-
plications were similar
Lee RCT, 60 THA Pre- and postoperative Lower VAS scores, ear-
et al.15 patients, multimodal sustained release oxy- lier ambulation with
vs. conventional codone and acetamin- crutches. No differ-
analgesia ophen; intra-operative ence in rate of com-
injection of morphine, plication, length of
methylprednisolone stay or narcotic
and ropivacaine consumption
Lavernia Cohort of 1136 Patient education, pre- Significantly less
et al.16 TKA patients, and post-operative chance of requiring
retrospective com- oxycodone, celecoxib manipulation under
parison of rate of and acetaminophen, anaesthesia for
arthrofibrosis femoral nerve block, arthrofibrosis
posterior capsular
injection of pain
cocktail
Duncan Evaluation of eco- Oxycodone extended Significantly decreased
et al.17 nomic impact; 100 release and rofecoxib mean direct hospital
patients of multi- preoperatively, lumbar cost (approximately
modal therapy with plexus regional block $2000)
historically matched with infusion catheter,
controls postoperative intrave-
nous ketorolac with
oral acetaminophen
and oxycodone
with bupivacaine should be used. In addition to pain relief, spinal–epi-

dural anaesthesia also provides the additional benefits like decreased risk
of deep vein thrombosis. In patients without respiratory and cardiovas-
cular compromise, intrathecal morphine should be added.
5. Regional blocks and injections: As far as regional blocks and
periarticular injections are considered, THA and TKA patients pres-
ent different scenarios. Usually THA patients do not have pain that is
severe enough to demand periarticular injection or regional block. If
deemed appropriate, a psoas compartment block of lumbar plexus using
an indwelling catheter is the block of choice.4 If fascia iliaca block is cho-
sen instead, the block should be administered postoperatively because of
the proximity of the insertion site to the surgical field.4 For TKA patients,
either periarticular injection or regional block (sciatic, femoral) should be
used. Some surgeons are apprehensive of regional block due to the fear of
weakness of muscle groups that lead to delayed rehabilitation and risk of
falls. For periarticular/intraarticular injections, continuous infusion devices
provide better postoperative pain control. However, these devices are best
avoided when some amount of native cartilage is preserved (e.g., partial
knee arthroplasty) because of risk of chondrolysis.
6. Postoperative pain management: THA patients experience com-
paratively less pain and can be continued on the same medications
used in pre-op cocktail (acetaminophen, celecoxib, pregabalin) can
be continued postoperatively, with addition of an opioid patient con-
trolled analgesia (Fentanyl PCA) for any breakthrough pain. In TKA
patients, intravenous ketorolac (30 mg, 6 hourly) should be used in
Table 5.2 Pre-operative cocktail
Preoperative cocktail Cautions

medications
1. Acetaminophen 1 g oral (can Avoided if patient has history
also be given intravenously) of liver disease or elevated
liver enzymes.
2. Celecoxib 400 mg oral (200 Contraindicated in sulfa allergy.
mg if patient is on celecoxib Substituted with naproxen 500 mg
preoperatively) orally.
3. Pregabalin 75 mg oral Avoided in elderly patients
with preexisting affection
of cognition because of
the risk of postoperative delirium.
place of celecoxib, starting from the evening of surgery till postopera-

tive Day 2.
7. Medical comorbidities: NSAIDs are avoided in patients with renal
insufficiency. In elderly patients, ketorolac dose is reduced to 15 mg
from the usual 30 mg. Antacids in form of proton pump inhibitors
should be added when using NSAIDs.
8. Role of opioids: Because of the risk of postoperative delirium and
respiratory depression, these are best avoided in patients older than 80
years. Opioids can be used as second line drugs for breakthrough pain
or residual pain. Tramadol (50–100 mg 6 hourly) is effective in mild to
moderate pain and Oxycodone (5–10 mg 4 hourly) is useful for moder-
ate to severe pain.
In some institutions, oral OxyContin (sustained release form of
Oxycodone) 20 mg every 12 hourly is used along with acetaminophen
for postoperative pain control for initial 48 h.4
9. Timing of medication: Planning to ensure that patient receives oral
pain medications one hour before the physical therapy sessions ensures
less discomfort and fewer disruptions.
10. Patient education: Among all psychological factors, pain catastro-
phizing is the strongest factor associated with pain experience.18 It is
defined as an exaggerated negative mental set brought to fore during
an actual or anticipated painful experience.19 Low preoperative mental
health and pain catastrophizing lead to more pain, worse function and
poorer quality of life after surgery.3,19 Addressing the mental health of
patient preoperatively, with particular attention to anxiety, depression,
expectations and catastrophizing should be done.
Author's Preferred Treatment

The authors believe in multimodal approach to pain control in dealing
with arthroplasty patients. It starts right from the first clinic visit when
the surgeon gets a first-hand information about the patient's perception to
postoperative pain, which differs in each individual. Hence, the approach
to each patient is different according to his or her perception and clini-
cian's day-to-day management. It starts right from preemptive analgesia in
the form of (a) patient education for expectation management and (b) oral
NSAIDs before surgery. Authors prefer a combined spinal–epidural anaes-
thesia for the analgesia during surgery, which continues as postoperative
epidural analgesia. Patient is simultaneously started on oral NSAIDs and
Fentanyl patch depending upon degree of threshold, these being contin-
ued even after removal of epidural catheter. Early, pain-free mobilization
remains the primary aim. Optimal oral analgesia is provided throughout the
early rehab period. Injectable Tramadol/NSAIDs are introduced for any
breakthrough pain during rehabilitation.
Exact duration of analgesic medications varies from patient to patient
based on functional needs. Almost all patients stop demanding analgesics
after a period of 2–3 weeks from surgery. However, the authors do not
prefer use femoral blocks or periarticular injections in their patients.
FUTURE DIRECTIONS
New research is throwing more light on how pain is processed in our brain.
In addition to the ascending pain pathway involving spinothalamic tract,
somatosensory and insular cortex, midline emotional systems in the supraspi-
nal lower brainstem and diencephalon now appear to play a significant role.20
These regions and the limbic system are involved in the autonomic, affective,
motivational, discriminative and cognitive aspects associated with the pain
sensation.20 Biopsychosocial models have suggested that physical, psycho-
logical and social factors must be considered to fully understand pain-related
outcomes.21 Further analyses of these avenues will allow development of
newer pharmacologic and non-pharmacologic (e.g., music therapy, cognitive
behavioral therapy) agents to act at various target sites to manage pain in a
better way, with perhaps less side effects. The future looks interesting.
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PART 2
Total Hip Arthroplasty:

Techniques and Pearls
Chapters
6. Radiological Planning of Total Hip Arthroplasty 75
7. Choosing Implant for Total Hip Arthroplasty 87
8. Tips and Pearls in Total Hip Arthroplasty 100
9. The Cemented Hip: How to Get it Right 118
10. Uncemented Total Hip Arthroplasty 138
11. Total Hip Arthroplasty in Peritrochanteric Fractures 149
12. Fused Hips in Ankylosing Spondylitis 156
13. Total Hip Arthroplasty in Protrusio Acetabulae 174
Chapter 6
Radiological Planning of Total

Hip Arthroplasty
Ivan De Martino, Peter K. Sculco, Georgios K. Triantafyllopoulos,
Lazaros A. Poultsides, Thomas P. Sculco
INTRODUCTION
Total hip arthroplasty (THA) is one of the most successful orthopaedic
procedures providing pain relief and improved function to patients with
end-stage degenerative joint disease. A thoughtful preoperative plan and
radiographic templating have an important role and increase the likeli-
hood of achieving a successful outcome. Preoperative templating gives
the treating surgeon information on several important surgical variables
and forces him to think in the three dimensions demanded during the
surgical procedure. How the prosthesis fits within the femoral canal and
provides insight on the correct type of implant and estimated size. Correct
acetabular component position can be assessed, and expected acetabular
coverage or undercoverage can be noted. Restoration of hip biomechan-
ics is necessary in a well-functioning THA, and templating provides data
on the degree of offset required for the proximal femur in addition to
projected leg lengthening. Radiographic templating allows the treating
surgeon to anticipate potential difficulties in the operating room and make
adjustments in advance leading to a reduction in intraoperative time and
complications.1–9 Templating contributes to more accurate leg length res-
toration and may reduce the risk of overlengthening, which is associated
with several postoperative complications including sciatic and femoral
nerve palsies,10 abnormal gait,11 low back pain,12 instability13 and aseptic
loosening.14 Leg-length discrepancy (LLD) leads to patient dissatisfaction15
and is one of the most common reasons for litigation against orthopaedic
surgeons.16 An accurate preoperative plan, including an appropriate history
and physical examination, radiographic evaluation and surgical templating,
is mandatory to improve intraoperative accuracy of leg length, offset, center
of rotation (COR) and component position. Müller17 in 1975 introduced
a method for preoperative planning in THA and since then it has been
considered an integral part of the surgical procedure and has remained
76 Part 2 | Total Hip Arthroplasty: Techniques and Pearls
remarkably unchanged. Templating in THA has traditionally been per-

formed using implant-specific acetate templates on hard copy X-rays. The
advance of digital radiography has led to digital templating and the use of
dedicated software. This is now becoming the standard technique in most
hip arthroplasty centers. In this chapter, we will describe the components
of a comprehensive and reliable preoperative radiological evaluation. This
will then be followed by presenting an established protocol for accurate
hip templating that can be applied to both hard copy and digital platforms.
PREOPERATIVE PLANNING
Radiological planning is a part of the preoperative planning when evaluating
a patient for a THA. An accurate diagnosis and indication for surgery is based
on patient symptoms in addition to radiographic findings. For this reason,
each surgeon should take an accurate medical history and perform a complete
physical examination in order to confirm the diagnosis and indications, and
educate the patient as to the details of the procedure. Surgical decisions such
as implant selection, bearing type and mode of implant fixation (cemented
versus uncemented) are influenced by age, sex, preoperative diagnosis, activity
level and mental status. A systematic assessment of the lumbosacral spine and
knee is performed to identify any extra-articular sources for hip pain. Flexion
contractures, previous scars and a neurovascular exam are then performed. True
and functional LLDs should be carefully evaluated and recorded. The true LLD
is determined clinically with the patient in the supine position measuring the
distance between the anterior superior iliac spine (ASIS) and the medial mal-
leolus. True LLD is usually secondary to bony hip pathology,18 especially with
femoral head collapse or severe hip dysplasia. A functional LLD is usually noted
by the patient in the standing position. Rigid blocks are placed under the foot
of the shorter leg until the leg lengths become subjectively even. Soft tissue
contractures (flexion and/or abduction) and scoliosis with pelvic obliquity are
the most common causes for functional LLD.18 Pelvic obliquity can be evalu-
ated by comparing the level of both hemipelvises with the patient sitting and
standing, and if present, the surgeon should assess whether its origin is suprapel-
vic, intrapelvic or infrapelvic. In the seated position, suprapelvic obliquity per-
sists usually secondary to a fixed lumbosacral scoliosis. In contrast, intrapelvic
and infrapelvic obliquity resolve in the seated position. Any clinical findings of
a significant LLD should also be confirmed radiographically.
Radiological Planning of Total Hip Arthroplasty 77
RADIOGRAPHIC TECHNIQUE
The standard preoperative radiographic evaluation for THA includes three
radiographs: an anteroposterior (AP) view of the pelvis and an AP and lat-
eral of the affected hip. The AP pelvis view is centered over the pubic sym-
physis and includes the proximal third of the femur to allow for templating
(Fig. 6.1 ). The AP views are obtained with the patient positioned supine
Fig. 6.1 The AP pelvis view. The beam is centered over the
pubic symphysis and includes the proximal third of the
femur to allow for templating.
on the radiographic table with the lower limbs in approximately 15°±5° of

internal rotation to allow a true AP view of the femoral neck, which has
a normal anteversion of 15°±5°. A well done AP pelvis view should have
neutral pelvic rotation and tilt. To determine the proper pelvic rotation, the
pubic symphysis should project on a line through the center of the sacrum
and coccyx, and the two obturator foramina should appear symmetrical.19
The pelvic tilt is estimated by the distance between the upper border of
the symphysis and the center of the sacrococcygeal joint. This distance
should be 2–3 cm above the superior end of the symphysis in males and
between 2–6 cm in females.20 This distance is increased when the pelvis
is tilted forward, and the AP view is close to an inlet view. Conversely,
this distance is decreased when the pelvis is tilted backwards, and the AP
view is close to an outlet view.20 In patients with a fixed external rotation
contracture who cannot internally rotate their hips, a posteroanterior (PA)
view of the femur should be obtained. This PA view is obtained with the
patient positioned prone on the radiographic table with the contralateral
hip elevated to an angle equivalent to the contracture. The most frequently
used lateral view of the hip is a modification of the frog-leg (Lowenstein)
lateral view (Fig. 6.2) and is obtained with the patient positioned supine
on the radiographic table with the affected hip externally rotated and the
knee and ankle flat on the table. This view is used for locating proximal
femoral entry point in the piriformis fossa.
Fig. 6.2 The lateral view of the femur. This is a modification

of the frog-leg (Lowenstein) lateral view.
Additional views may be necessary and dependent on the history and

physical examination. Cross-sectional imaging should be obtained in the
case of a pelvic fracture or dislocation, in addition to standard Judet views
(obturator oblique and iliac oblique). Bone quality and the geometry of the
proximal femur can be assessed using the indexes of Singh21 and Dorr.22
The Singh index is commonly used to assess osteoporosis and is based on
the density of trabecular bone of the proximal femur21 and the Dorr classi-
fication classifies the geometry of the proximal femoral canal. Both indexes
contribute to decision making on implant type and mode of implant fixation.22
RADIOGRAPHIC TEMPLATING IN THA
Step 1: Determination of Magnification

Surgeons must be aware of the amount of magnification of the hip radio-
graphs before templating. Usually with the X-ray tube at 100 cm from the
top of the table and the X-ray tray placed 5 cm below the table, magnifica-
tion is 20% (± 6%, 2 SDs) as soft tissues are interposed between the hip and
the X-ray plate.23 To match the radiographic magnification, acetate templates
are usually 10–20% oversized. Attention should be paid to the patient’s
body habitus because magnification is directly proportional to the distance
between the pelvis and the film. Therefore, increased magnification should
be anticipated in extremely obese patients and, conversely, less magnification
would be expected in extremely thin patients.24 If the radiographies are digi-
tized, they must be calibrated before templating.25,26 A radio-opaque marker,
such as sphere which is 25 mm in size27 or a coin with a known size,25 is
usually used as a calibration tool in order to scale the dimensions shown on
the radiograph and the digital templates. These markers should be at the same
level of the hip joint in the AP plane. Usually they are positioned near the
greater trochanter or between the patient’s legs, close to the pubis, on the
greater trochanter’s plane.28 Alternatively, when a contralateral hip prosthesis
of known dimension is present, it can be used as a calibration tool.
Step 2: Radiographic Landmarks Identification

There are several radiographic landmarks that should always be identified and
are useful for preoperative templating: the ilioischial line (Kohler’s line), the
base of the teardrop, and the superolateral margin of the acetabulum (Fig. 6.3)
at the acetabular side; the lesser and the greater trochanter and the medul-
lary canal at the femoral side. The radiographic teardrop (also known as the
U-figure) is located in the inferomedial portion of the acetabulum, just above
the obturator foramen. The teardrop is a consistent radiographic landmark and
is in close proximity to the center of hip rotation and the acetabular floor.29
The ilioischial line, or Kohler's line, is drawn from the medial border of the
ilium to the medial border of the ischium, and is a useful landmark when
assessing the degree of protrusio acetabuli. The superolateral margin of the
acetabulum provides a reference for the degree of osseous coverage around the
implanted acetabular component. During the surgical procedure, these land-
marks should be identified to convert the two-dimensional planning, made on
the X-rays, into the in vivo three-dimensional intraoperative situation.
Fig. 6.3 Radiographic landmarks identification. The radio-

graphic teardrop (in green), the ilioischial line (in red) and
the superolateral margin of the acetabulum (in blue).
Step 3: Determination of Leg-Length Discrepancy

To assess preoperative LLD, a pelvic horizontal reference line is made
using the lower margin of the two teardrops and drawing an interteardrop
line (Fig. 6.4). If the teardrops are not identifiable, a horizontal reference
line can be drawn through the distal aspect of the ischial tuberosities or
the distal aspect of the sacroiliac joints. The LLD at the hip can be cal-
culated as the difference in the vertical distance between the horizontal
reference line and a fixed point on the femur (Fig. 6.5). Fixed points on
the femur could be the lesser trochanter, the greater trochanter or the
center of the femoral head. LLD may be present at a level distal to the hip
joint, such as in case of bony abnormalities (osteotomies or malunions) or
functional limitations (hip or knee contractures). In this case, LLD should
be assessed on a standing AP view radiograph, with the distance measured
between the interteardrop line and the floor.
Step 4: Acetabular Templating

Acetabular templating is always performed first because it establishes the
Fig. 6.4 Identification of the pelvic reference line. In this case, the inter-teardrop line is
drawn through the lower margin of the two teardrops.
new COR after component implantation. Using the previously described

pelvic radiographic landmarks, the template should be oriented to achieve
an abduction angle of 40°–45° in relation to the interteardrop line, with the
inferomedial border of the cup seated near the ilioischial line, or the lateral
edge of the teardrop (Fig. 6.6). The superolateral margin of the acetabulum
is used as a reference for the coverage of the cup, and final component
size should maximize cup coverage while avoiding excessive subchondral
Fig. 6.5 Digital templating. The leg-length discrepancy

(LLD) is calculated as the difference in the vertical distance
between the horizontal reference line and the most medial
aspect of the lesser trochanter. The calibration ball is posi-
tioned between the patient’s leg (arrow).
Fig. 6.6 Digital acetabular templating. The template should be oriented to achieve an
abduction angle of 40°–45° in relation to the interteardrop line, with the inferomedial
border of the cup seated near the lateral edge of the teardrop. The center of rotation
of the cup is marked.
bone resection. The COR should be medialized in order to decrease the

moment arm generated by the patients body weight during the gait cycle,
theoretically reducing wear30,31 and improving clinical outcomes.32 In
cemented cups, a uniform 2–3 mm space should be left for cement mantle.
Once final acetabular implant size and position have been determined, the
new COR of the hip should be marked and compared to the contralateral
side for vertical and horizontal symmetry.
Protrusio Acetabuli
The cup should be lateralized to increase femoral offset and decrease cup-neck
impingement. The cup template should be positioned in the anatomic posi-
tion, adjacent to the lateral edge of the teardrop and lateral to the ilioischial line.
Lateralized Acetabulum
The cup should be medialized as much as possible in order to gain the
proposed benefits of improved postoperative hip biomechanics. The cup
template should be positioned in the anatomic position, adjacent to the
lateral edge of the teardrop and lateral to the ilioischial line.
Dysplastic Acetabulum
Dysplastic hips present challenging acetabular and femoral anatomy and
require careful preoperative planning. Basic radiographs will show the

superolateral migration of the femoral head and insufficient acetabular
coverage. To replace the socket in these cases, the surgeon must decide
between two options a ‘high hip center’ or an ‘anatomic hip center’
and template accordingly.33,34 If a well-established pseudoacetabulum is
present, the cup may be placed at a high hip center. However, placing
the cup in this position results in a lateralized hip COR that increases
failure rate.33,35 If the cup is placed in the anatomic position, near the
lateral edge of the teardrop, the result is usually an inadequate supero-
lateral bony coverage. A 10–20% of bony uncoverage can be accepted,
and if additional coverage is needed, a femoral head bone autograft can
be used.
Step 5: Femoral Templating

Once the COR of the reconstruction is marked, the femur can be tem-
plated from this point. The goal of the femoral templating is to choose an
implant that permits adequate fixation and restores offset and leg length.
To achieve this result, it is important to consider both the intraosseous
parameters (stem fixation and alignment) and the extraosseous param-
eters (offset and leg length). Stem size is best determined on the AP view
radiograph, and depends on stem type choice (straight or anatomic),
fixation choice (cemented or cementless) and coating choice (proxi-
mally coated or fully coated). For a proximally coated cementless stem,
emphasis should be given to the proximal fit and fill. For an extensively
coated stem, fixation must be achieved distally, and a diaphyseal isthmic
fill should be achieved. For a cemented stem, a uniform 2–3 mm cement
mantle should be considered. The entry point (piriformis fossa) and the
fit of the stem should be assessed on both AP and lateral views. Once the
stem size is decided, the template should be positioned inside the femoral
canal, along the longitudinal femoral axis, and the COR of the femoral
head should be marked (Fig. 6.7A). Attention should be paid in cases of
coxa vara or coxa valga. Now, the positions of both centers of rotation
(femoral and acetabular) should be checked. The vertical and horizontal
distances between those points represent the change in limb length and
offset that will be obtained. If the two centers of rotation are overlapped,
leg length and offset will remain unchanged. If the COR of the femoral
stem lies medially to the COR of the acetabular cup, femoral offset will
be increased. Conversely, if the COR of the femoral stem lies laterally to
the COR of the acetabular cup, femoral offset will be decreased. If the
A B
Fig. 6.7 Digital femoral templating on the anteroposterior (AP) view radiograph. The
template is positioned inside the femoral canal, along the longitudinal femoral axis,
and the center of rotation of the femoral head is marked (A). The distances between the
proximal corner of the lesser trochanter and the center of rotation of the femoral head
as well as the proposed neck cut level are also determined (B).
COR of the femoral component lies more proximally than the COR of
the acetabular cup, lengthening of the limb will occur. Conversely, short-
ening of the limb will be the result if the COR of the femoral compo-
nent lies more distally than the COR of the acetabular cup. Leg length
should be restored based on the patient’s history and clinical examination
as previously mentioned. Once the offset and the femoral head COR
are determined, the level of the femoral neck cut can be marked. The
distances between the proximal corner of the lesser trochanter and the
COR of the femoral head as well as the proposed neck cut level are also
determined at this point (Fig. 6.7B). The width of the calcar, medial to
the stem at the level of the neck cut is determined, so as to help the
surgeon during intraoperative stem alignment assessment at the frontal
plane (varus or valgus). At this point, if templating for a cemented stem,
plug size and insertion depth should be calculated based on the stem size.
SUMMARY
Preoperative planning and templating play an important role in modern hip
joint reconstruction and likely improve the probability of achieving a successful
outcome in THA. Preoperative planning helps the surgeon decide the type, size
and position of the femoral and acetabular components in addition to giving
information on offset and leg length parameters that must be restored, while
allowing this to be performed in an expeditious and accurate manner. As a final
note, while preoperative radiographic templating gives the surgeon an opera-
tive road map to follow, final surgical decisions will be based on intraoperative
factors that continue to rely on surgical experience.
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10. Nercessian OA, Piccoluga F, Eftekhar NS. Postoperative sciatic and femoral nerve palsy
with reference to leg lengthening and medialization/lateralization of the hip joint fol-
lowing total hip arthroplasty. Clin Orthop Relat Res 1994;304:165–71.
11. Gurney B, Mermier C, Robergs R, et al. Effects of limb-length discrepancy on gait
economy and lower extremity muscle activity in the older adults. J Bone Joint Surg Am
2001;83:907–15.
12. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg
length inequality. Spine 1983;8:643–51.
13. McCollum DE, Gray WJ. Dislocations after total hip arthroplasty. Causes and preven-
tion. Clin Orthop Relat Res 1990;261:159–70.
14. Ramaniraka NA, Rakotomanana LR, Rubin PJ, Leyvraz P. Non-cemented total hip
arthroplasty: influence of extramedullary parameters on initial implant stability and on
bone-implant interface stresses. Rev Chir Orthop 2000;86:590–97.
15. Ranawat CS. The pants too short, the leg too long! Orthopedics 1999;22:845–46.
16. Hofmann AA1, Skrzynski MC. Leg-length inequality and nerve palsy in total hip
arthroplasty: a lawyer awaits! Orthopedics 2000;23:943–44.
17. Müller ME. Total hip replacement: planning, technique and complications. In: Cruess
RL, Mitchell NS, eds. Surgical Management of Degenerative Arthritis of the Lower Limb.
Philadelphia, PA: Lea and Faber;1975:90–113.
18. Ranawat CS, Rodriguez JA: Functional leg-length inequality following total hip arthro-
plasty. J Arthroplasty 1997;12:359–64.
19. Massin P, Schmidt L, Engh CA. Evaluation of cementless acetabular component migra-
tion. An experimental study. J Arthroplasty 1989;4:245–51.
20. Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retrover-
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21. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the
femur as an index of osteoporosis. J Bone Joint Surg Am 1970;52:457–67.
22. Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH. Structural and
cellular assessment of bone quality of proximal femur. Bone 1993;14:231–42.
23. Clarke IC, Gruen T, Matos M, Amstutz HC. Improved methods for quantitative
radiographic evaluation with particular reference to total-hip arthroplasty. Clin Orthop
1976;121:83–91.
24. Carter LW, Stovall DO,Young TR. Determination of accuracy of preoperative templat-
ing of noncemented femoral prostheses. J Arthroplasty 1995;10:507–13.
25. Conn KS, Clarke MT, Hallet JP. A simple guide to determine the magnification of
radiographs and to improve the accuracy of preoperative templating. J Bone Joint Surg
Br 2002; 84:269–72.
26. Oddy MJ, Jones MJ, Pendegrass CJ, Pilling JR, Wimhurst JA. Assessment of reproduc-
ibility and accuracy in templating hybrid total hip arthroplasty using digital radiograph.
J Bone Joint Surg Br 2006;88:581–85.
27. White SP, Shardlow DL. Effect of introduction of digital radiographic techniques on pre-
operative templating in orthopaedic practice. Ann R Coll Surg Engl 2005;87:53–4.
28. Wimsey S, Pickard R, Shaw G. Accurate scaling of digital radiographs of the pelvis. A
prospective trial of two methods. J Bone Joint Surg 2006;88:1508–12.
29. Goodman SB, Adler SJ, Fyhrie DP, Schurman DJ. The acetabular teardrop and its rel-
evance to acetabular migration. Clin Orthop Relat Res 1988;236:199–204.
30. Sakalkale DP, Sharkey PF, Eng K, Hozack WJ, Rothman RH. Effect of femoral compo-
nent offset on polyethylene wear in total hip arthroplasty. Clin Orthop 2001;388:125–34.
31. Schmalzried TP, Shepherd EF, Dorey FJ, et al. Wear is a function of use, not time. Clin
Orthop 2000;381:36–46.
32. Charnley J. Low Friction Arthroplasty of the Hip: Theory and Practice. Berlin, Germany:
Springer-Verlag;1979:246.
33. Russotti GM, Harris WH. Proximal placement of the acetabular component in total hip
arthroplasty. A long-term follow-up study. J Bone Joint Surg Am 1991;73:587–92.
34. Callaghan JJ, Salvati EA, Pellicci PM, Wilson PD Jr, Ranawat CS. Results of revision for
mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-
year follow-up. J Bone Joint Surg Am 1985; 67:1074–85.
35. Pagnano MW, Hanssen AD, Lewallen DG, Shaughnessy WJ.The effect of superior place-
ment of the acetabular component on the rate of loosening after total hip arthroplasty.
J Bone Joint Surg Am 1996;78:1004–14.
Chapter 7
Choosing Implant for Total Hip

Arthroplasty
Georgios K. Triantafyllopoulos, Ivan De Martino, Peter K. Sculco,
INTRODUCTION
The success of total hip arthroplasty (THA) in relieving pain and improv-
ing function in patients with advanced hip arthritis is undisputed. Certainly,
besides surgical technique, the implants that are used also play a considerable
role to the procedure’s success. Since Sir John Charnley introduced the con-
cept of low friction arthroplasty in the 1960s, advances in materials, implant
design and surgical techniques, as well as conclusions from long-term studies
of patients with THA have contributed to the development of contempo-
rary implants. A wide range of implant options is offered today. However,
different designs abide by some principles which can help categorize them.
Even though absolute indications for each type of prosthesis remain debat-
able, orthopaedic surgeons should be familiar with the basic concepts behind
various acetabular cup and femoral stem options, so that they can make the
right selection for any given patient. Moreover, implant selection can be
influenced by factors related not only to the patient but to the surgeon as
well. All these aspects will be discussed in the subsequent section.
THE ACETABULAR CUP

Acetabular options include cemented and cementless cups. Cemented cups
are monoblock and provide immediate mechanical stability. They can be
utilized in cases with a compromised biologic environment, such as meta-
bolic bone disease, postirradiation and renal carcinoma. On the other hand,
the demanding technique along with initial concerns for higher rates of
aseptic loosening led to a gradual decline in their use, especially in North
America. However, recent evidences do not confirm inferior survivorship
of cemented cups as compared to cementless options.1
Currently available cementless acetabular cups rely on an initial press-
fit fixation, followed by subsequent bone ingrowth over an appropriately

textured surface. Their shape can be hemispherical or elliptical. Press-fit
fixation is achieved through under-reaming of the native acetabulum either
1 or 2 mm. Sequential reaming of the acetabulum should be done until
optimal contact with the acetabular rim and dome is achieved. Insertion
of a component with a diameter greater by 1–2 mm than the last reamer
will provide maximum interference fit at the acetabular rim, while allowing
contact of the dome of the cup with the medial acetabular wall, ensuring
component medialization. When initial press-fit fixation is not considered
optimal (e.g., when repositioning of the cup is required), supplemental fixa-
tion can be obtained with the use of screws; spikes, fins or pegs are other
alternatives. Porous surface texture provides an osteoconductive milieu for
bone ingrowth. There are several different porous coatings, including grit-
blasted or plasma sprayed titanium, titanium fiber-metal and, more recently,
‘trabecular’ metal. Crystalline hydroxyapatite (HA), known for its osteo-
philic properties, has also been used as coating. All these options have been
proven clinically successful.2–5 Modular cementless cups are widely used, as
they offer flexibility in terms of liner selection, and simplify future revision
procedures due to liner wear. Modularity brings potential issues including
locking mechanism failure and polyethylene backside surface wear. The
effective joint space is expanded through the screw holes and accumulated
debris can access the ilium and lead to acetabular osteolysis. Monoblock
cups with compression molded polyethylene (Fig. 7.1) were introduced to
address these concerns, but nonetheless offer less intraoperative versatility.
In terms of level of constraint, liners that enclose the femoral head have
been used in cases of anticipated postoperative instability or in revision
cases. A major disadvantage of constrained liners is the increased risk of
early aseptic loosening, due to the excessive shear stresses applied to the
cup–bone interface. Dual mobility or tripolar cups, which feature a dual
articulation of the polyethylene liner with the femoral head and with the
acetabular cup, can be used in selected patients with concurrent or antici-
pated instability. Concerns of increased linear wear have not been substanti-
ated; however, dual mobility cups are related with the unique complication
of ‘intraprosthetic dislocation’ of the polyethylene liner.6–9
THE FEMORAL STEM

Cemented fixation of the femoral stem was the technique originally
used after the introduction of THA in clinical practice. Whereas not that
Choosing Implant for Total Hip Arthroplasty 89
Fig. 7.1 Acetabular monoblock cup with 10° liner directly compression molded into
the metal shell.
popular in North America, cemented stems are still quite frequently used
in Europe.10 Long-term studies of patients with Charnley hip arthro-
plasty have demonstrated an excellent survivorship when revision for
aseptic loosening of the femoral component was used as the end-point.11,12
Since the initial Charnley stem, many changes in implant design as well
as advances in the bone cement preparation technique were introduced.
There are two philosophies behind contemporary cemented stem designs.
Both facilitate transmission of axial and torsional loads to the bone, while
maintaining mechanical stability.
The composite beam concept (Fig. 7.2A) is based on establishing a
strong bond between the stem and the acrylic cement. Axial loads are
transmitted through the stiffer stem to its distal part and then to the adja-
cent bone, increasing the risk of stress shielding. The addition of a collar
intends to distribute part of the loads to the proximal bone earlier, as well
as to unload the proximal cement mantle, which is susceptible to crack
formation. Shear stresses at the stem–cement interface are substantial,
and the disruption of the bond can result in micromotion, production of
cement and metallic debris and loosening of the implant. Composite beam
stems are straight or anatomically shaped. The latter offer the potential of
better centralization within the femoral canal and of a more evenly dis-
tributed cement mantle.
The loaded taper philosophy (Fig. 7.2B) incorporates a collarless stem
with a shape tapered in one or more planes and a highly polished surface.
The stem is embedded into the cement mantle but rather than bonding
with it, it initially further subsides until sufficient hoop stresses are created
and transferred to the bone.12 The polished surface facilitates subsidence
and diminishes wear debris from micromovement in the cement–stem
interface. Moreover, the absence of a strong stem–cement mantle bond
reduces tensile stress in the interface. However, compressive forces do not
depend on such a bond. Overall, with the loaded taper design, axial loads
are transmitted to the metaphyseal bone relatively early, thus theoretically
reducing the risk of proximal stress-shielding. Despite the fact that good
mid- and long-term results have been reported with both a polished13
and a rough surface cemented stem,14,15 there are comparative studies that
discourage the use of a textured or matte-surface stem.16,17 Differences in
the cross-sectional shape also exist, with oval and square stems available,
but their effect on implant performance and survivorship is not clear.18
Regardless the philosophy of the stem though, meticulous cement tech-
nique, including avoidance of excessive reaming, preparation of the cement
A B
Fig. 7.2 Cemented stems. (A) Composite beam type. (B) Loaded taper type.
in vacuum and proper pressurization, is of paramount importance for

ensuring the longevity of the implant.
Cementless femoral stem fixation was initially introduced as an alter-
native for younger and more active patients, even though today its use is
frequently expanded in older age groups. As is the case with the acetabular
cup, good bone biology is a prerequisite as it provides the potential for
bone ingrowth. Of course, bony ingrowth also depends on adequate initial
mechanical stability of the prosthesis. Ingrowth is promoted by the appro-
priate surface porosity, which can be acquired with sintered cobalt–chrome
beads or plasma-sprayed titanium. HA coating has also been used to pro-
mote bone ongrowth.
Based on the extent of the porous coated surface, cementless femoral
stems can be divided into two large categories: extensively and proximally porous
coated. Extensively porous coated stems attain broad fixation. However, from a
biomechanical point of view, when a stem of this type is used and is securely
fixed to its most distal part at the isthmus, axial loads bypass proximal bone,
leading to bone remodeling and resorption (stress shielding).19 Proponents of
extensively porous coated stems point out that stress shielding does not com-
promise fixation.20 However, in case of a future revision for a reason other
than loosening, extensive ingrowth complicates implant removal, necessitat-
ing a more extensile approach and compromising an already deteriorated
bone stock. On the other hand, extensively porous coated stems can be used
in cases of revision surgery, where proximal bone loss warrants distal fixation.
In proximally coated stems, only the proximal third of the stem is porous or
hydroxyapatite coated and fixation involves only its metaphyseal part. When
the hip is axially loaded, loads are transferred to metaphyseal bone, therefore
reducing the risk of stress shielding. Despite their different philosophy, in a
comparative prospective study, the clinical outcome of the two types was
similar and the only difference was a greater reduction in bone mineral den-
sity in Gruen zone 7 with the extensively coated stem.19
Based on their shape, cementless femoral stems can be divided into
tapered, anatomical and straight cylindrical. Tapered stems have a rectan-
gular cross-section, which allows them to achieve initially both axial and
rotational stability (Fig. 7.3A–D). Their shape may be tapered in frontal or
both frontal and sagittal planes (single-tapered and double-tapered, respec-
tively), and options may include variations such as flattened, round, conical
and rectangular shapes.21 This shape facilitates initial fixation. Some of these
types (e.g., flattened and rectangular) do not require any reaming but only
broaching. The absence of a shoulder may also accommodate for a more
medial entry point. Fixation is achieved proximally, therefore allowing for a
more eccentric seating of the stem tip and minimizing the risk of fracture
and thigh pain. Recently, shorter variations of the tapered design have been
introduced. These facilitate bone stock preservation and are compatible
with minimally invasive surgical techniques.22
Anatomic stems are tailored to the anatomy of the femur (Fig. 7.3E–F).
As secure diaphyseal fit is very important for this type of implant, reaming
of the femoral canal is necessary (fit and fill concept). The diverse femoral
anatomy observed among patients and the risk of femoral fractures are
concerns with this type of implant. Nevertheless, reported clinical results
of their use have been excellent.23,24
Cylindrical stems (Fig. 7.3G) are extensively coated or proximally
coated and also require reaming of the femoral canal, as distal fixation is
crucial. In fact, distal fixation is important not only for axial but also for
rotational stability. Fitting a cylindrical stem in an under-reamed femoral
canal by 1–2 mm provides better rotational fixation initially than line-
to-line reaming. However, when femoral canal under-reaming is applied,
A B C D
E F G
Fig. 7.3 Cementless stems. (A and B) Single wedged tapered stem. (C and D) Rectangular
tapered stem. (E and F) Anatomic stem. (G) Straight cylindrical, extensively coated stem.
insertion of the stem should be done with caution, as fracture of the femur
is not an uncommon complication. As already stated, extensively porous
coated cylindrical stems are associated with proximal stress shielding. In
spite of these concerns, long-term survival of this type of prostheses has
been reported to be excellent.25
BEARING SURFACES
Several options of bearing surface combinations have been offered
throughout the years of THA clinical application. Bearing surfaces can be
roughly divided into two large categories: hard-on-soft and hard-on-hard.
Hard-on-soft bearings refer to the use of a polyethylene acetabular liner
and either a metallic or a ceramic femoral head. On the other hand, hard-
on-hard bearings include ceramic-on-ceramic and metal-on-metal com-
binations. Metal-on-polyethylene bearings incorporate an articulation of a
cobalt–chrome alloy femoral head against a highly cross-linked, ultra-high

molecular weight polyethylene liner. In ceramic-on-polyethylene bear-
ings, a similar liner is used, but the femoral head is composed of a ceramic
material. Polyethylene wear with the production of large particle debris
and consequent osteolysis remains a significant problem with these con-
figurations. Ceramic-on-polyethylene bearings have been shown to exhibit
a better wear profile and thus are considered appropriate for younger
and more active patients.26 Improvements in ceramic materials have been
related with a decreased risk for head fracture, although that risk cannot
be completely overlooked, especially in the younger patient. A consider-
able research effort has focused in improving polyethylene properties and
minimizing linear wear. Sterilization in the absence of air, increase of cross-
linking through remelting or annealing27 and vitamin E impregnation28 are
methods of improving polyethylene wear resistance. Highly cross-linked
polyethylene exhibits a better linear wear profile compared to traditional
polyethylene, but its mechanical properties in terms of fatigue resistance,
ductility, tensile strength and toughness are inferior.
Ceramic-on-ceramic bearings are not related with polyethylene
wear-related problems, but require accurate cup positioning, as deviations
can result in impingement or edge loading, and consequent squeak-
ing or fracture of the ceramic components.29 Despite initial enthusiasm
about metal-on-metal bearings, their use has been disfavored because of
issues regarding metal ion release and adverse local tissue reactions.30,31
Therefore, as newer polyethylene liners exhibited a better wear behavior,
hard-on-soft bearings were gradually widely endorsed. Polyethylene lin-
ers can be combined with a wide range head sizes, including those with
larger diameters. Potential future wear and osteolysis can be treated with
liner exchange and bone grafting.32
PATIENTRELATED FACTORS
Implant selection should always be individualized to the needs and charac-
teristics of each patient. Factors that should be considered include patient
age, bone quality and anatomy, and co-morbidities that may affect the
procedure’s success.
In the very young patient, as modern mean life expectancy can exceed
80 years, bone and soft tissue preservation is of paramount importance.
Therefore, implants in this group of patients should accommodate to
these goals. Cementless press-fit fixation is the method of choice in
younger patients. The presence of indwelling instrumentation, short-stature

with small acetabular and proximal femoral size, as well as concomitant
bone metabolic disease are factors that may affect the ultimate decision.
Nonetheless, as discussed below, surgeon preference also plays an integral
role in the process of implant selection, even under these circumstances. As
a future revision seems inevitable, another important variable that might
affect implant selection in the younger patient population is the ease of
revision. Unfortunately, certain approaches to achieve this, such as increased
femoral stem modularity, have not been proven successful.33
On the other end of the spectrum are patients older than 75 years.
Often, these patients have compromised bone quality and osteoporosis or
lower level of activity, and may benefit from cemented fixation. Cemented
fixation has shown satisfactory and reproducible results in this group of
patients.34,35 However, cement-related morbidity, and most importantly,
respiratory complications in a patient with a possibly already compromised
respiratory and cardiovascular function, along with excellent reported
results of cementless fixation,36 have led to a gradual increase in the use of
press-fit options, even in patients of greater age.
In cases of hip dysplasia, atypical anatomy warrants the use of smaller
or even custom-made femoral stems and cemented cups. The role of pre-
operative planning in these patients is even more critical. Modular stems
with proximal cementless fixation are commonly used. In certain cases
where proximal bone stock is inadequate, diaphyseal fixation through an
extensively coated, cylindrical stem is warranted. Finally, concomitant con-
ditions including rheumatoid arthritis or previous irradiation of the pelvic
region could necessitate cemented fixation options. The senior author’s
suggestions regarding the use of an uncemented vs. a cemented stem are
summarized in Fig. 7.4.
SURGEONRELATED FACTORS
In a recent survey among orthopaedic surgeons,37 100% stated that they
use uncemented acetabular components, with 48% adding no augmenta-
tion, 44% using additional screw fixation and 7% using implants with
spikes or fins. As per femoral options, more than 95% of the responders
reported the use of uncemented stems in more than 50% of their cases,
with 47% using this option in all of their patients. Tapered stems seem to
be widely preferred, as use of double-tapered stems was reported by 53%
of surgeons, whereas single-tapered stems were routinely used by 38% of
Poor bone biology Yes

(e.g. previous irradiation)
No
No Yes
Age > 75 years
Other anatomic
No considerations No Dorr Type C
(e.g. fracture Proximal Femur
malunion,
dysplasia) Yes
Yes
Uncemented fixation Cemented fixation

Fig. 7.4 General recommendations for the use of uncemented vs. cemented stems.
responders. For cemented stems, composite beam designs were the pre-
ferred option among survey participants (65%). When polyethylene bear-
ings were chosen, invariable use of either a metallic or a ceramic head was
reported by 65% of surgeons, with 80% preferring the use of a head *36
mm in diameter. Undoubtedly, surgeon preference and familiarity with a
certain implant or technique are very important parameters. Even in the
hands of a skilled surgeon, a new technique is associated with a respective
learning curve. Other procedures, such as cementing a cup, can be very
demanding. It should also be noted that clinical experience plays a key role
in selecting an implant, as surgeons can be reluctant in choosing a prosthe-
sis that they are not familiar with. On the other hand, as recent experience
has shown, a considerable number of clinicians can be prompted to use a
novel implant that seems advantageous, but has not been supported with
solid evidence, leading to detrimental consequences. Often there is a grey
zone between evidence-based support and marketing of an implant, and
the industry puts pressure on using novel and costly implants. However,
hospital payments for joint replacements have not been increasing with
the same rate as implant costs. Some hospital organizations could there-
fore advocate the use of less expensive implants, leading to a conflict with
surgeons.38 It is the surgeons’ responsibility to use an implant that will
provide favorable and reproducible long-term outcomes, using current
best evidence and sound clinical reasoning.
SUMMARY
Contemporary implant options offer great versatility and can address the
needs of almost every patient with end-stage hip arthritis undergoing THA.
While all of these options exhibit roughly equivalent short-term results, it
is their performance in the long-term that can affect selection. Surgeons
should have knowledge of the basic concepts behind different designs and
their advantages and disadvantages, as well as should take into consideration
distinct patient characteristics. Finally, they should keep in mind that even
the appropriate selection of the best available implant cannot ensure a suc-
cessful outcome without a sound surgical technique.
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2. Engh CA, Hopper RH, Jr, Engh CA, Jr. Long-term porous-coated cup survivorship
using spikes, screws, and press-fitting for initial fixation. J Arthroplasty 2004;19(Suppl
2):54–60.
3. Reina RJ, Rodriguez JA, Rasquinha VJ, Ranawat CS. Fixation and osteolysis in
plasma-sprayed hemispherical cups with hybrid total hip arthroplasty. J Arthroplasty
2007;22:531–34.
4. Urban RM, Hall DJ, Della Valle C, Wimmer MA, Jacobs JJ, Galante JO. Successful long-
term fixation and progression of osteolysis associated with first-generation cementless
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5. Poultsides LA, Sioros V, Anderson JA, Bruni D, Beksac B, Sculco TP. Ten- to 15-year
clinical and radiographic results for a compression molded monoblock elliptical acetab-
ular component. J Arthroplasty 2012;27:1850–56.
6. Adam P, Farizon F, Fessy MH. Dual articulation retentive acetabular liners and wear:
surface analysis of 40 retrieved polyethylene implants. Rev Chir Orthop Reparatrice Appar
Mot 2005;91:627–36.
7. Philippot R, Boyer B, Farizon F. Intraprosthetic dislocation: a specific complication of
the dual-mobility system. Clin Orthop Relat Res 2013;471:965–70.
8. Boyer B, Philippot R, Geringer J, Farizon F. Primary total hip arthroplasty with dual
mobility socket to prevent dislocation: a 22-year follow-up of 240 hips. Int Orthop
2012;36:511–18.
9. Philippot R, Farizon F, Camilleri JP, et al. Survival of cementless dual mobility socket with
a mean 17 years follow-up. Rev Chir Orthop Reparatrice Appar Mot 2008;94:e23–e27.
10. Murray DW. Cemented femoral fixation: the north Atlantic divide. Bone Joint J
2013;95B(11 Suppl A):51–2.
11. Callaghan JJ, Albright JC, Goetz DD, Olejniczak JP, Johnston RC. Charnley total hip
arthroplasty with cement. minimum twenty-five-year follow-up. J Bone Joint Surg Am
2000;82:487–97.
12. Shen G. Femoral stem fixation. an engineering interpretation of the long-term out-
come of charnley and exeter stems. J Bone Joint Surg Br 1998;80:754–56.
13. Ling RS, Charity J, Lee AJ, Whitehouse SL, Timperley AJ, Gie GA. The long-term
results of the original exeter polished cemented femoral component: a follow-up report.
J Arthroplasty 2009;24:511–17.
14. Callaghan JJ, Liu SS, Firestone DE, et al. Total hip arthroplasty with cement and use of
a collared matte-finish femoral component: nineteen to twenty-year follow-up. J Bone
Joint Surg Am 2008;90:299–306.
15. Vail TP, Goetz D, Tanzer M, Fisher DA, Mohler CG, Callaghan JJ. A prospective ran-
domized trial of cemented femoral components with polished versus grit-blasted sur-
face finish and identical stem geometry. J Arthroplasty 2003;18(7 Suppl 1):95–102.
16. Datir SP, Kurta IC, Wynn-Jones CH. Ten-year survivorship of rough-surfaced femoral
stem with geometry similar to charnley femoral stem. J Arthroplasty 2006;21:392–97.
17. Della Valle AG, Zoppi A, Peterson MG, Salvati EA. A rough surface finish adversely affects
the survivorship of a cemented femoral stem. Clin Orthop Relat Res 2005;436:158–63.
18. Scheerlinck T, Casteleyn PP.The design features of cemented femoral hip implants. J Bone
Joint Surg Br 2006;88:1409–18.
19. MacDonald SJ, Rosenzweig S, Guerin JS, et al. Proximally versus fully porous-coated
femoral stems: a multicenter randomized trial. Clin Orthop Relat Res 2010;468:424–32.
20. Engh CA, Jr, Young AM, Engh CA S, Hopper RH, Jr. Clinical consequences of stress
shielding after porous-coated total hip arthroplasty. Clin Orthop Relat Res 2003;417:157–63.
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arthroplasty. J Bone Joint Surg Am 2011;93:500–09.
22. Patel RM, Stulberg SD. The rationale for short uncemented stems in total hip arthro-
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24. Kawamura H, Dunbar MJ, Murray P, Bourne RB, Rorabeck CH. The porous coated
anatomic total hip replacement. A ten to fourteen-year follow-up study of a cementless
total hip arthroplasty. J Bone Joint Surg Am 2001;83-A:1333–38.
25. Engh CA, Hopper RH, Jr. The odyssey of porous-coated fixation. J Arthroplasty
2002;17(4 Suppl 1):102–07.
26. Kim YH. Comparison of polyethylene wear associated with cobalt-chromium and
zirconia heads after total hip replacement. A prospective, randomized study. J Bone Joint
Surg Am 2005;87:1769–76.
27. Callary SA, Field JR, Campbell DG. Low wear of a second-generation highly cross-
linked polyethylene liner: a 5-year radiostereometric analysis study. Clin Orthop Relat
Res 2013;471:3596–600.
28. Oral E, Christensen SD, Malhi AS, Wannomae KK, Muratoglu OK. Wear resistance and
mechanical properties of highly cross-linked, ultrahigh-molecular weight polyethylene
doped with vitamin E. J Arthroplasty 2006;21:580–91.
29. D’Antonio JA, Sutton K. Ceramic materials as bearing surfaces for total hip arthroplasty.
J Am Acad Orthop Surg 2009;17:63–8.
30. Bosker BH, Ettema HB, Boomsma MF, Kollen BJ, Maas M, Verheyen CC. High
incidence of pseudotumour formation after large-diameter metal-on-metal total hip
replacement: a prospective cohort study. J Bone Joint Surg Br 2012;94:755–61.
31. Smith AJ, Dieppe P,Vernon K, Porter M, Blom AW, National Joint Registry of England
and Wales. Failure rates of stemmed metal-on-metal hip replacements: analysis of data
from the National Joint Registry of England and Wales. Lancet 2012;379:1199–1204.
32. Haidukewych GJ, Petrie J. Bearing surface considerations for total hip arthroplasty in
young patients. Orthop Clin North Am 2012;43:395–402.
33. Cooper HJ, Urban RM, Wixson RL, Meneghini RM, Jacobs JJ. Adverse local tissue
reaction arising from corrosion at the femoral neck-body junction in a dual-taper stem
with a cobalt-chromium modular neck. J Bone Joint Surg Am 2013;95:865–72.
34. Ekelund A, Rydell N, Nilsson OS. Total hip arthroplasty in patients 80 years of age and
older. Clin Orthop Relat Res 1992; 281:101–06.
35. Levy BA, Berry DJ, Pagnano MW. Long-term survivorship of cemented all-polyethyl-
ene acetabular components in patients > 75 years of age. J Arthroplasty 2000; 15:461–67.
36. Healy WL. Hip implant selection for total hip arthroplasty in elderly patients. Clin
Orthop Relat Res 2002; 405:54–64.
37. Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee arthroplasty
among members of the American Association of Hip and Knee Surgeons. J Arthroplasty
2010;25(6 Suppl):2–4.
38. Healy WL, Iorio R. Implant selection and cost for total joint arthroplasty: conflict
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Chapter 8
Tips and Pearls in Total Hip

Arthroplasty
Ivan De Martino, Georgios K. Triantafyllopoulos, Peter K. Sculco,
INTRODUCTION
Total hip arthroplasty (THA) is one of the most common and successful
surgical procedures over the past 50 years,1 and has been proven to decrease
a patient's pain and improve function and quality of life.2 Despite variations
in surgical technique and implant selection, several studies have demonstrated
over 90% implant survival at minimum 10 years.3 In order to relieve pain and
improve function and quality of life in patients undergoing a THA, it is man-
datory for a surgeon to restore or maintain the center of rotation and offset,
ensure equal limb length and achieve durable implant fixation and stability.
There are several different exposures to perform a THA today: the anterior
(Smith-Peterson4), anterolateral (Watson-Jones5), direct lateral (Hardinge6),
posterolateral (Moore7) and direct posterior (Gibson8). The direct anterior
approach (DAA) allows the surgeon to approach the hip through an interner-
vous and intermuscular plane, thus demonstrating potential advantages over
other surgical approaches to the hip. Specifically, it does not violate the integ-
rity of the iliotibial band, greater trochanter and hip abductor muscles, thereby
potentially reducing the risk for painful THA.9 Studies have shown that recov-
ery of gait and hip function was more rapid after DAA compared with the
miniposterior approach10 and that postoperative hip dislocation precautions
are not required following DAA.11 Supine position may offer an advantage to
the intraoperative cardiovascular and pulmonary monitoring, facilitate poten-
tial urgent need for airway and cardiopulmonary access and intervention, and
furthermore, provide a direct way to equalize leg-length discrepancy (LLD)
during surgery.12 By far, the most common surgical technique is the postero-
lateral approach. This is utilized in approximately 70% of cases performed
in the United States. The current trend is to use less invasive approaches to
perform a THA. Even though absolute indications for each approach remain
debatable, orthopaedic surgeons should learn the basic strategy and concepts
required for successful execution of a primary THA. In the following section,

we discuss the mini-incision posterolateral surgical technique as described by
the senior surgeon13 (TPS), with particular emphasis on patient positioning,
surgical exposure, implant positioning and LLD assessment.
AUTHOR’S PREFERRED METHOD

Complete history and physical examination are performed for all patients.
After a complete radiographic evaluation (anterior–posterior pelvis and
lateral view of the hip), a meticulous preoperative planning and templating
are performed. We use multimodal hypotensive epidural anaesthesia (HEA)
for the vast majority of our patients and reserve general anaesthesia for rare
instances in which spinal or epidural anesthesia cannot be performed for
technical or medical reasons (e.g., severe degenerative disease of the lumbar
spine). HEA has been shown to decrease perioperative morbidity, including
thromboembolic disease.14 A second surgical benefit of this type of anaes-
thesia is a reduction of intraoperative blood loss, which facilitates visualiza-
tion during hip implantation.14 Prophylactic antibiotics are administered
intravenously at least 30 min before skin incision (e.g., a second generation
cephalosporin or vancomycine due to patient allergy). We use a multi-
modal postoperative deep vein thrombosis/pulmonary embolism (DVT/
PE) prophylaxis, both pharmacologic and mechanical; 325 mg of aspirin
twice daily in addition to pneumatic compression and early mobilization.
Coumadin is preferred over aspirin in high risk patients.
POSITIONING OF THE PATIENT

Proper patient positioning is a
prerequisite for accurate exposure
and intraoperative assessment of
the pelvic position during acetabu-
lar component implantation. After
induction of epidural anaesthesia,
the patient is positioned in the
lateral decubitus position on a well-
Fig. 8.1 Patient is placed in the lateral padded hip table (Fig. 8.1 ). In
decubitus position on a well-padded order to secure the patient so the
standard hip surgical table with the surgi- ASIS is perpendicular to the plane
cal side up.
A of the floor and not rotated, the

pelvis is secured with padded ante-
rior (pubic) and posterior (sacral)
post supports (Fig. 8.2). We also
cover the anterior pubic post with
an inflatable pad, to improve stabi-
lization and protect the skin from
B
excessive pressure. An inflatable
shoulder float is placed below the
axilla to avoid injury to the axil-
lary nerve and reduce postoperative
shoulder discomfort (Fig. 8.3). The
back is also stabilized with a poste-
Fig. 8.2 The pubic region is secured rior thoracic support to prevent any
with padded pubic post support (A)
forward or backward rolling of the
(arrow). The sacral region and the back
are secured with padded sacral and tho- body. All of the bony prominences
racic post supports (B) (arrows). are padded. The nonsurgical leg is
secured with a belt in a position
of slight hip flexion and 90° of knee flexion. A foam rubber pad is also
positioned between the knees in order to retain a neutral position of both
extremities (Fig. 8.4). Shaving of the surgical site is done with an electric
shaver in the pre-op holding area and before the draping procedure. The
skin from the calf to the pelvis is prepared with an antiseptic solution
Fig. 8.3 An inflatable shoulder float is placed below the

axilla to avoid injury to the axillary nerve and reduce post-
operative shoulder discomfort (arrow).
(povidone-iodine or chlorexidine). The operative limb is covered with

sterile Iobane® drapes to allow full mobility of the limb during the opera-
tive procedure, which is essential during the exposure of the proximal
femur and during the implantation of the femoral prosthesis.
Fig. 8.4 A foam rubber pad positioned between the knees

to retain a neutral position of both extremities.
INCISION AND EXPOSURE

The anatomic landmarks for the surgical incision are marked with a skin
marker including the proximal, anterior and posterior borders of the
greater trochanter and the vastus ridge. In cases of overweight patients,
wherein the greater trochanter can be difficult to palpate, rotation of the
limb can help in identifying it. A straight skin incision begins in the mid-
dle of the femur at the level of vastus ridge and extends 1–2 cm proximal-
ly over the posterior corner of the greater trochanter for a total incision
length of 8–10 cm (Fig. 8.5). Approximately, one-third of the incision
extends proximal to the tip of the greater trochanter. Distally, the incision
follows the axis of the distal femur, whereas proximally follows the direc-
tion of the underlying gluteus maximus fibers and is slightly curved in the
posterior direction. In obese patients, a longer incision may be required in
order to avoid excessive pressure on the skin edges. An incision shorter
than 6 cm should be avoided, as it increases the risk of skin bruising and
blistering. After the skin incision is made, subcutaneous tissue is incised
and retracted in line with the skin incision. The fascia lata is also incised
in the line of the skin incision, between the middle and posterior third of
the greater trochanter along the axis of the femur. The gluteus maximus
is gently split along its fibers cranially using blunt finger dissection to
Fig. 8.5 The anatomic landmarks for placement of skin incision include the proximal tip
of the greater trochanter, the anterior and posterior borders of the greater trochanter
and the vastus ridge. For the mini posterolateral approach, the length of skin incision
ranges from 6 to 10 cm.
expose the proximal part of the great trochanter. Two cotton laps soaked
in saline are applied to the skin edges and a Charnley self-retaining retrac-
tor is placed deep to the fascial layer while carefully protecting the sciatic
nerve. The leg is positioned in neutral extension, and the hip is gently
internally rotated with a padded Mayo stand under the foot for support.
The trochanteric bursa is then incised and the fat pad behind the great
trochanter reflected posteriorly with a surgical lap sponge. The short
external rotators are exposed with a Cobb elevator (Fig. 8.6). Haemostasis
of the deep medial femoral circumflex vessels is achieved with electro-
cautery. The piriformis is palpated and separated from the inferior border
of the gluteus medius with a blunt
dissection to create an anatomic
interval. Angled at 90°, Hohmann
retractor is placed underneath the
gluteus medius in this interval
and an Aufranc retractor is placed
immediately adjacent to the proxi-
mal margin of the quadratus femo-
ris below the inferior capsule and
the femoral neck. At the junction of
Fig. 8.6 Intraoperative picture showing
the exposure of the external rotators of the piriformis and gluteus minimus,
the hip (arrow). the piriformis, conjoined tendon
and underlying capsule are released as a single layer from the posterior
border of the femoral neck, extending distally to the level of the lesser
trochanter. A portion of quadrates femurs muscle may be released in the
distal portion of this incision. This creates a single soft tissue sleeve that
is then tagged with two nonabsorbable sutures for later posterior soft
tissue repair. The first suture is through the piriformis tendon and cap-
sule and the second suture through
the conjoined tendon and capsule
(Fig. 8.7). With further flexion,
adduction and internal rotation, the
femoral head is then dislocated pos-
teriorly. In difficult cases, placing
a bone hook around the femoral
neck may help. The limb is then
internally rotated 90°. The center
of the femoral head is marked with
Fig. 8.7 The tendons and capsule are electrocautery and the lesser tro-
tagged using two No. 2 non-absorbable
tagging sutures (arrow). chanter is identified. The distance
from the lesser trochanter to the
center of the femoral head is measured intraoperatively (Fig. 8.8) and
compared with the preoperative plan. The level of the neck cut level is
based on the preoperative plan. The femoral neck osteotomy is perfor-
med with a thin oscillating reciprocating saw, starting from the medial
calcar towards the great trochanter (Fig. 8.9). Attention must be paid to
prevent notching of the greater trochanter or injuring the sciatic nerve.
Care should be taken to make sure the saw blade is perpendicular to the
Fig. 8.8 The distance from the less tro- Fig. 8.9 The reciprocating saw allows for
chanter to the center of the head is mea- optimal control and gradual change of
sured and the neck osteotomy level is direction, decreasing chance of notching
marked. greater trochanter.
long axis of the femur so as to prevent an oblique femoral neck cut. The
femoral head is removed using a tinaculum pointed clamp and a twisting
motion to disrupt remnant of the ligamentum teres (Fig. 8.10).
Fig. 8.10. The femoral head is removed using a tinaculum

pointed clamp.
PREPARATION OF THE ACETABULUM AND

POSITIONING OF THE ACETABULAR COMPONENT
After the femoral neck cut is completed the leg is returned to a neutral
position. The femur is retracted with an angled C-shaped Hohmann
retractor (Fig. 8.11) over the anterior wall of the acetabulum. A
Steinman pin is placed into the supra-acetabular region (ilium) to retract
the gluteus medius and minimus
superiorly. The inferior capsule is
incised to relieve the tension and
a wide angled Hohmann retrac-
tor (Fig. 8.11) is inserted into the
posterior wall of the acetabulum
between the labrum and the poste-
rior capsule using a mallet to gain
bone fixation. An Aufranc retrac-
tor (Fig. 8.11) is placed initially
Fig. 8.11. Retractors used for mini-inci- inferior to the transverse acetabular
sion posterior lateral approach used to ligament and moved above the liga-
facilitate acetabular exposure. From left to
right: (1) C-retractor, (2) Aufranc, (3) road ment after further inferior capsular
bent Hohmann and (4) Bent Hohmann. release. The acetabular labrum and
overhanging peripheral soft tissues

are then excised with a long-han-
dled scalpel. The full circumference
of the acetabular socket should be
exposed (Fig. 8.12). The pulvinar is
excised with a long electrocautery
tip to prevent bleeding from the
ligamentum teres vessels. Peripheral
osteophytes are generally removed
Fig. 8.12 Bend retractors allow excellent after the cup is impacted in its final
visualization of the acetabulum.
position using a broad osteotome
and a rongeur. The acetabulum is initially sequentially reamed in a pro-
gressive and concentric manner with an offset handled reamer. The initial
reamer is roughly 6 mm smaller than template’s acetabular cup size and is
inserted directly into the wound in order to remove the medial osteophyte
and expose the true acetabular floor (medial wall) (Fig. 8.13). Then, the
surgeon brings the reamer to the desired lateral abduction and anteversion
and the periphery of the acetabulum is incrementally (2 mm increments)
reamed to the desired size (Fig. 8.14), until sufficiently bleeding subchon-
dral bone is exposed throughout the acetabular wall, and good rim contact
with the reamer is achieved. The correct arrangement of the retractors,
and especially the inferior Aufranc retractor, allows for adequate inferior
A B
Fig. 8.13 The acetabulum is initially sequen- Fig. 8.14 After the exposure of the medial
tially reamed with an offset handled reamer wall, the reamer is brought to the desired
(A). The initial reamer is inserted directly into lateral abduction and anteversion and the
the wound in order to remove the medial periphery of the acetabulum is incremen-
osteophyte and expose the true acetabular tally reamed to the desired size.
floor (medial wall) (B).
mobilization of the skin (mobile window) and helps placing the reamers
horizontally enough to achieve the desired cup position. After acetabular
reaming is concluded, a trial shell is inserted and fully seated to verify
size, orientation and stability of the cup. The surgeon, especially beginner,
should note the position of the trial shell so that the acetabular cup can
be inserted in the same position. Screws can be added to increase fixation
if is needed. The senior surgeon’s preference for primary cases is the use
of a monoblock cup. This is an elliptical monoblock cup with a direct
compression molded polyethylene into a trabecular metal shell. Due to the
elliptical shape, the cup is 2 mm wider in the periphery comparing to a
hemispherical cup and reaming is performed to 1 mm below the external
rim circumference, thus providing a stable rim fit. With a vertically placed
medializing impactor, the cup is initially brought medially (Fig. 8.15). It is
then impacted axially to the desired
orientation. Before press-fitting the
cup, its position is checked with
an angle guide which rests on the
acetabular rim (Fig. 8.16), and fine
adjustments can be made with the
impaction of a shovel placed on
the appropriate positions of the rim
A B (Fig. 8.17). Once optimal orienta-
tion is achieved, the cup is press-fit-
Fig. 8.15 The cup is attached to an insert-
er (A) and a few taps are applied initially
ted with a ball impactor to its final
to a vertically placed impactor in order position. In our practice, for a pri-
medialize the cup (B). mary total hip arthroplasty, we opt
Fig. 8.16 An angle guide is used to assess Fig. 8.17 Cup insertion tools. From left to
the cup orientation. Optimal cup position right: (1) medial cup impactor, (2) cup rim
is considered a coronal inclination angle impactor and (3) angle guide.
of 45° and an anteversion of 20°.
for a medial and inferior placement of the acetabular cup (in line with the
plane connecting the two teardrop signs in the AP pelvis X-ray), in order
to restore the normal hip joint center of rotation and biomechanics. The
optimal lateral abduction angle of the cup is considered to be 40°–45°,
whereas desired cup anteversion is 15°–25°. Nevertheless, cup anteversion
should be always considered in combination with femoral anteversion and
the goal should be obtaining a combined anteversion of 25° to 35° for
men and 30° to 45° for women. This further stresses the importance of
scrutinizing preoperative radiographs and templating.
PREPARATION OF THE FEMUR AND POSITIONING OF

THE FEMORAL COMPONENT
After the actabular cup implantation is completed, the Charnley retractor
is removed and the femur is 90° internally rotated, flexed and adducted.
Two clean laps are used to protect the skin and a third lap sponge is
inserted into acetabular shell to protect the polyethylene and shell. The
proximal femur is delivered into the mobile window, and exposure is
aided with a narrow femoral neck retractor (modified toothed Aufranc
retractor) placed on the anterior neck. An Aufranc retractor is placed
along the inferior/medial neck below the lesser trochanter and pref-
erably in contact with the modified Aufranc retractor used to lift the
femur. A C-retractor is placed anterior to the greater trochanter into the
trochanteric fossa superiorly to separate the gluteus minimus and medius
muscles which provides exposure to the femoral neck and protects the
abductors during subsequent reaming and broaching of the femoral canal
(Fig. 8.18). It is the senior author’s preference to use a splined femoral
stem to enhance rotational stability of the final implant. Once the retrac-
tors have been placed around the
proximal femur, the remaining lat-
eral cortex of the neck is removed
with a curved gouge placed at the
junction of the femoral neck and
the greater trochanter. The femoral
canal is subsequently opened with
a rasped cylindrical reamer. Care
is taken to lateralize the femoral
Fig. 8.18 The proximal femur is delivered canal during reaming, in order to
into the incision with the aid of retractors. avoid varus insertion of the stem.
Sequential reaming of the distal portion of the canal is performed with

a straight reamer, until adequate cortical contact is reached (Figs 8.19–
8.20). Broaching of the proximal femur is then carried out, with the
broaches inserted with approximately 10°–15° of anteversion and follows
the patients native version (Figs 8.20–8.21). The posterior neck cortex
in relation to the epicondyles of the knee with the leg perpendicular to
the floor can be used as a reference for determining anteversion. The
broach size is then incrementally increased until adequate fit and rota-
tional stability are achieved. A calcar planer is used to remove any excess
bone around the neck of the final trial broach once the handle has been
detached (Fig. 8.22). A rongeur may also be used at this time to remove
Fig. 8.19 Femoral canal preparation using Fig. 8.20 Femoral component preparation
cylindrical reamers. tools.
Fig. 8.21 Broaching of the femoral canal Fig. 8.22 A calcar planer is used to remove
using the appropriate femoral rasps. any excess bone around the neck of the
final trial broach once the handle has
been detached.
any osteophytes located usually at the anterior aspect of the femoral

neck. After insertion of the trial neck and a standard head (+0 mm) of
the appropriate diameter, the hip is reduced, and cup coverage and com-
bined anteversion of the components are evaluated (Fig. 8.23). In addi-
tion, the hip is brought to range of motion to check for impingement
and instability (for more details, see the section on leg length and soft
tissue balancing). After confirming appropriate positioning, the broach is
removed and the chosen implant is inserted. Irrigation is not performed
before the insertion of the prosthesis as a press-fit stem is used, and autog-
enous bone should not be removed from the canal. Again, care is taken
to maintain the desired anteversion during impaction of the stem to its
final position (Fig. 8.24). A final femoral head is impacted onto a clean
and dry femoral stem taper.
A B
Fig. 8.23 Trial reduction is always per- Fig. 8.24 Intraoperative image show-
formed in order to assess offset, leg ing the impaction of the final femoral
length, range of motion and hip stability. component, taking care to ensure cor-
rect rotational alignment (A). The femoral
stem used by the senior surgeon relies on
proximal fixation for initial stability and is
enhanced by the distal splines for added
rotational stability (B).
REDUCTION AND CLOSURE

Once the implants have been placed and reduced, the wound is irrigated via
pulsed lavage and haemostasis achieved. The short external rotators, including
the conjoined tendon and the piriformis tendon, as well as the posterior joint
capsule are repaired through two transosseus holes in the greater trochanter
and ideally in the site of the native insertions (Fig. 8.25). The sutures are pas-
Fig. 8.25 Using a 3.2 mm drill bit, two transosseus tunnels

are created in the posterolateral aspect of the greater tro-
chanter.
sed through the drill holes with a suture passer and tied in slight abduction
and external rotation to allow the posterior tissues to come in close proximi-
ty to the femur. Two 12 mm drain tubes are placed under the fascia, and the
wound is copiously irrigated with normal saline using pulsatile lavage. The
fascia lata is closed with interrupted 0 Vicryl sutures. The wound is closed
in layers. A sterile dressing is then placed over the wound, which is wrapped
in a hip spica fashion using an Ace bandage. The final position of the leg
is secured using an abducting pillow. The patient is then transferred to the
recovery room. In order to prevent a perioperative dislocation, standard hip
precautions for a posterolateral approach are followed.
It should be highlighted that although this technique applies to the

majority of patients undergoing primary total hip arthroplasty via a pos-
terolateral approach, each patient should be carefully evaluated before
surgery to identify factors that would warrant a modification of this
approach. For example, patients with ankylosing spondylitis frequently
compensate vertebral deformity with hip hyperextension. This can lead
to a propensity of placing the cup in a more vertical and anteverted
position, which in combination with the increased femoral anteversion,
frequently seen in these patients, increases the risk of anterior dislocation.
Hence, in such patients, cup orientation and femoral anteversion should
be adjusted accordingly. Another example is the patient with hip dyspla-
sia and high congenital dislocation, where placement of the cup in the
anatomic position is not feasible. In these patients, a high-hip center can
be a viable option, provided that adequate medialization is achieved, as
lateral placement of a high-center cup is associated with poor hip biome-
chanics. In summary, preoperative planning together with sound surgical
technique can ensure the appropriate positioning of both implants, so as
to obtain the optimal functional outcome and abate the risk of mechani-
cal complications.
ENSURING LIMB LENGTH EQUALIZATION

AND STABILITY
The process of preserving limb length or restoring LLD during total
hip arthroplasty begins with preoperative templating. The perpendicular
distance between the proximal corner of the lesser trochanter and the
interteardrop line is measured for both sides and any difference noted
represents the LLD that needs to be restored. The results should always
be compared to the clinical limb length measurements performed dur-
ing patient evaluation. After templating for the acetabular and femoral
components (Fig. 8.26), the vertical distance between the centers of rota-
tion of the acetabular cup and the femoral stem represents the change in
limb length that will be obtained. This could be either lengthening (if
the femoral component’s center of rotation is more proximal than that of
the acetabular cup) or shortening of the limb (if the femoral component’s
center of rotation is more distal than that of the acetabular cup). Similarly,
if the center of rotation of the femoral stem lies medially to the center of
rotation of the acetabular cup, femoral offset will be increased and vice
versa. The distances between the proximal corner of the lesser trochanter
and the center of rotation of the femoral head (lesser trochanter center
[LTC] ), as well as the level of the femoral neck osteotomy are also deter-
mined (Fig. 8.26). For more details regarding preoperative templating, the
reader is referred to the relevant section. Intraoperatively, the findings of
preoperative templating need to be confirmed. After dislocating the hip,
the proximal corner of the lesser trochanter is released and exposed, the
center of the femoral head is determined and the distance between these
two points is measured and compared to the LTC distance measured
during preoperative templating, to evaluate for accuracy of preoperative
measurements. The level of the neck osteotomy is also marked. Once the
surgeon has proceeded with neck osteotomy, after reaming and broaching
of the femoral canal and with the final broach in place, a trial femoral
neck and a femoral head of the appropriate diameter are inserted. The
selection of a neck with a standard or an extended offset depends on
the findings of preoperative templating with a general goal of using the
midrange of available neck lengths. Moreover, a femoral head with the
largest possible diameter accommodated by the acetabular cup is prefer-
Fig. 8.26 Preoperative digital templating.

able (up to 36 mm), as it is well established that a greater head/neck ratio

increases range of motion and stability of the implant. After inserting the
selected femoral neck and a +0 head, the LTC distance is determined
again (Fig. 8.27). If there is a difference with the LTC measured before
the neck osteotomy, then a femoral head of longer or shorter length is
inserted. The hip joint is reduced and the surgeon assesses soft tissue ten-
sion, range of motion and stability. Soft tissue tension can be evaluated
with the drop kick test and the shuck test. In the drop kick test, when
Fig. 8.27 Measurement of the distance from the lesser

trochanter to the center of the head ensures adequate leg
length.
the hip is brought to extension, the knee should remain in flexion. If the
knee is extended with this maneuver, then soft tissue tension is too tight.
The shuck test involves telescopic distraction of the femoral head from
the acetabulum, which should only allow for a few millimeters of transla-
tion. Range of motion is then evaluated and any restriction, particularly
in internal or external rotation, is indicative of tight soft tissue tension.
The presence of gross instability is also assessed. Finally, the impingement
test is performed, by adducting and internally rotating the hip and assess-
ing for hip stability and range of motion before impingement occurs. As
noted earlier, if any modifications are deemed necessary after these tests,
fine adjustments can be made by using different neck and head offsets and
lengths. An effort should be made to avoid the use of femoral heads with
excessive lengths, as they exhibit reduced head/neck ratio and therefore

limit range of motion before impingement ensues. This further under-
lines the importance of careful preoperative planning. Once optimal hip
biomechanics is achieved, the chosen femoral stem and head are inserted,
the hip is reduced and the surgeon proceeds with closure. Careful repair
of the posterior capsule with the technique described earlier is critical for
enhancing hip stability after total hip arthroplasty.
It must be noted that it is not within the senior surgeon’s practice to intra-
operatively assess LLD by palpating the patient’s knees and/or feet. Careful
preoperative templating, accurate intraoperative measurements, reproducing
and confirming preoperative measurements, and restoration of the periarticu-
lar soft tissue tension, as evaluated with the maneuvers described earlier, are
considered adequate for preserving equal limb lengths or addressing any LLDs.
SUMMARY
The most common surgical technique to perform a primary THA is the
posterolateral approach. Most surgeons around the world are familiar to this
approach. The current trend is to use minimal invasive approaches to per-
form a THA. However, this approach should not be utilized in patients with
severe dysplasia, in revision surgery or in patients with a body mass index
greater than 35 kg/m2. Ensure an accurate patient positioning is mandatory
for an accurate cup positioning. A meticulous planning and templating are
essential for an adequate femoral neck cut osteotomy level and restoration
of limb length and offset. Special instrument should be used to facilitate
minimal invasive surgery. If in doubt, the incision should be more extensive.
Finally, surgeons should keep in mind that a well-performed operation is
much more important than a short incision.
REFERENCES
1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip
replacement. Lancet 2007;370:1508–19.
2. Ethgen O, Bruyere O, Richy F, et al. Health-related quality of life in total hip and
total knee arthroplasty. A qualitative and systematic review of the literature. J Bone
Joint Surg Am 2004;86-A:963–74.
3. Soderman P, Malchau H, Herberts P. Outcome after total hip arthroplasty: part I:
general health evaluation in relation to definition of failure in the Swedish national
total hip arthroplasty register. Acta Orthop Scand 2000;71:354–59.
4. Smith-Peterson MN. Approach to and exposure of the hip joint for mold arthroplasty.
5. Watson-Jones R. Fractures of time neck of time femur. Br J Surg 1930;23:787–808.

6. Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br 1982;64:17–19.
7. Moore A. The self-locking metal hip prosthesis. J Bone Joint Surg Am 1957;39:811–27.
8. Gibson A. Vitallium-cup arthroplasty of the hip joint: review of approximately 100
cases. J Bone Joint Surg Am 1949;31:861–68.
9. Goebel S, Steinert AF, Schillinger J, Eulert J, Broscheit J, RudertM, Nöth U. Reduced
postoperative pain in total hip arthroplasty after minimal-invasive anterior approach.
Int Orthop 2012;36:491–98.
10. Nakata K, Nishikawa M,Yamamoto K, Hirota S,Yoshikawa H. A clinical comparative
study of the direct anterior with miniposterior approach: two consecutive series. J
Arthroplasty 2009;24:698–704.
11. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip
arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005; 441:115–24.
12. Unger AS, Stronach BM, Bergin PF, Nogler M. Direct anterior total hip arthroplasty.
Instr Course Lect 2014;63:227–38.
13. Sculco TP. Minimally invasive total hip arthroplasty: in the affirmative. J Arthroplasty
2004;19(4 Suppl 1):78–80.
14. Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a
review. Acta Orthop Scand 1996; 67:91–107.
Chapter 9
The Cemented Hip: How to

Get it Right
Atul Panghate
INTRODUCTION
Our journey into the world of hip arthroplasty started when Sir John
Charnley performed the first cemented hip replacement in 1954 in England.
Even today, hip replacement remains one of the most successful surgeries.
With more than half a century of experience, we have learnt a lot and
modified our surgeries and prostheses to achieve outstanding results.
Important lessons that we have learnt from multiple studies and registry
data:1–5
1. Quality and adequacy of cement mantle are the most important fac-
tors in deciding the longevity of the cemented hip.
2. Poor quality of polyethylene, leading to early wear, osteolysis and
loosening, is an important cause of failure.
3. Some designs have done exceedingly well over the long term, and
should be preferred over others.
Small changes in designs or coatings can lead to disastrous results. So
beware of ‘look-alikes’ or ‘copies’ of successful designs. Hence, for good
long-term results, choose a prosthesis based on registry data and clinical
studies. The bearing surface with the least wear rate should be chosen,6
for example, highly cross-linked polyethylene cup on metal/ceramic head.
The surgeon must meticulously perform his bone preparation and
cementing technique to achieve good depth of cement penetration and
mechanical interlock at bone and cement interface.7,8
It is very critical to understand that thorough bony preparation, wash-
ing and cleaning with pulsatile lavage, good pressurized cementing and
perfect positioning of implant will ensure good long-term survival of the
cemented hip.
The aim should be to place the cup at the perfect position and centre
of rotation, with a good cement penetration in bone and a strong mantle.
After evaluating results from multiple studies, the author prefers a
flanged, highly cross-linked polyethylene cup with polymethyl meth-
The Cemented Hip: How to Get it Right 119
acrylate (PMMA) spacers, without extended posterior lip.9–11 Extended

posterior lips are known to lead to neck–lip impingement with a risk of
poly-wear and late dislocations.
TEMPLATING
A line is drawn, joining the bottom of the bilateral teardrops on antero-
posterior (AP) pelvis radiograph. The limb length discrepancy due to the
acetabulum and the femur is measured with respect to this line. The offsets
are measured as distances between the lesser trochanter and the center of
head, and between the piriformis fossa and the center of head and noted
down for intra-op correlation. Then a point is taken, 1 cm lateral to the
most inferior point of teardrop (this corresponds to the transverse acetabu-
lar ligament (TAL) during surgery), which is the planned lower extent of
cup. A line is drawn at 45° from this point, and the point at which it crosses
the superior rim of the acetabulum is marked, corresponding to the intra-
op superior end-point of the cup. Using the sizing templates provided by
the implant manufacturer, the size of the component is noted to avoid over
reaming intraoperatively.
SURGICAL TECHNIQUE
Hypotensive anaesthesia with systolic BP < 90 mm of Hg is preferred,
which is usually achieved by spinal and/or epidural anaesthesia, to achieve
good cement preparation and avoid bleeding in the interface.
EXPOSURE OF THE ACETABULUM

The surgeon must use the exposure that he is most familiar with and
one that gives him the best results. But a complete (360°) exposure of
the acetabulum is the most critical step in cementing the cup. Correct
placement of retractors after release of tight structures, (reflected head
of rectus femoris, capsule,gluteusmaximus, etc.) whenever needed,
should be done.
A pin is placed at 12 O’clock position, which helps to retract the gluteus
medius and also acts as a fixed landmark on ilium for accurate limb length
correction. Sharp, narrow retractors are then placed around the anterior
and posterior rims of acetabulum. The inferior capsule is then released to
expose the TAL and a blunt Hohmann’s retractor is placed under the TAL
in the acetabular notch to achieve a complete exposure (Fig. 9.1).
A C
Fig. 9.1 (A) Good exposure. (B) Newer retractors. (C) Pre-op
limb length measured from a fixed pelvic landmark.
The anatomic landmarks are then marked to get the center of rotation
(COR) of hip correctly restored. The anterior, posterior, superior rims of
the acetabulum and the TAL are marked. Erosions and deficient parts of
the acetabulum are then marked. The anterior superior iliac spine, ischial
tuberosity and lumbar spine are palpated to appreciate pelvic tilts and rota-
tions. Acetabular osteophytes are then marked and should be preserved
until the cup has been cemented, as the osteopyhtes may enhance cement
containment and aid cement pressurization. However, in some cases, with
very large osteophytes, these have to be partially removed early to facilitate
access to the acetabulum.
IDENTIFICATION OF THE MEDIAL WALL OF PELVIS

It is important to identify the true medial wall of the acetabulum. If the
ligamentumteres is not ossified, it can be excised to reveal the fossa acetabuli.
However, the ligamentous fibers are invariably overgrown by central osteo-
phyte formation. Resecting the central overhanging osteophyte, prior to
reaming, using an osteotome or a sharp curette, exposes the true floor of
the acetabulum. This will ensure adequate roof coverage and medialization
of the component.
REAMING THE ACETABULUM

After the inner floor has been identified, a small reamer is placed horizontally
in the unroofed acetabular fossa, and directed medially, until the medial wall
is reached. Once the medial wall is reached, the cancellous bone of the fossa
becomes flush with the cortical surface of the floor, which corresponds radio-
graphically to the lateral border of the teardrop. After medial wall reaming, the
following reamers are directed superiorly to enlarge the cavity, but no attempt
is made to remove the eburnated roof sclerosis. The last reamer should be the
AP diameter of the acetabulum on lateral projection (Fig. 9.2). If one goes by
inferior to superior size of the acetabulum, one can err towards over-reaming of
Fig. 9.2 Initial reaming should be horizontal to avoid later-

alization of hip centrer.
the acetabulum. As a rule of thumb, the largest and final reamer size should only
exceed the AP diameter by 2–4 mm. Finally, a smaller sized reamer, which can
easily be maneuvered in all directions like a burr, is used, to roughen the scle-
rosed roof till it shows bleeding bone. Finally, osteophytes are trimmed so that
the cup can be placed in the desired position. The new acetabulum rim cutter is
a handy instrument to trim the overhanging osteophytes and expose the cancel-
lous bone for accurate placement of the cup and for better cementing (Fig. 9.3).
ANCHORING HOLES
Anchor holes are drilled in reamed acetabulum, so that there is better pen-
etration of the cement into cancellous bone and strong cement bone interface
Fig. 9.3 Rim Cutter: The Rim Cutter (an instrument which cuts a rim into the acetabulum
and is not intended to cut the rim of the implant) marked with the same size as the cup
OD to be inserted is attached to the power reamer. The Rim Cutter is designed to cut a
groove in the periphery of the acetabulum of the appropriate diameter for the flange.
Do not use Rim Cutter if there is inadequate bone stock. The hemisphere on the Rim
Cutter centralizes the cutter in the reamed socket and sets the depth of the rim and
thus the position of the cup. Each Rim Cutter has to be used with its correct hemispheri-
cal guide. If the acetabulum is reamed to 56mm, use Rim Cutter size 54 with 54 green
hemispherical guide. (Source: Exeter X3 RimFit Acetabular Cup Surgical Technique).
(Fig. 9.4). Multiple anchoring holes of approximately 6–8 mm depth are made in
all the zones using a flexible drill. Care has to be taken not to perforate the thin
anterior, posterior or medial walls. Smaller anchor holes in ischium and pubis are
made, as large holes in these areas were known to be loaded in tension and lead
Fig. 9.4 Packing of morselized bone in Fig. 9.5“Retractor Aspirator”/“Iliac Sucker”-

obturator foramen (blue) to avoid pelvic Fluid is sucked out of the wing of the
spillage of cement (red). ilium by the sucker aspirator to get blood/
fluid less field for cementing. (Source:
Exeter X3 RimFit Acetabular Cup Surgical
Technique).
to de-bonding of cement mantle and unnecessary bone loss. A newly designed

(Stryker inc. USA) ‘Iliac Sucker’ can now be inserted at 12 O’clock position,
about 1 cm away from the acetabular rim (Fig. 9.5).
BONE BED PREPARATION
Pulsatile Lavage
Pulsatile lavage is a very important step towards good cementing. It
helps in removing the soft tissue, blood, bone and marrow particles from
cancellous bone, thus helping in good pressurized cementing. Before
the last wash, the acetabular cavity is packed with hydrogen peroxide or
norepinephrine soaked pack to reduce bleeding and better penetration
of cement. Some surgeons use a brush to remove the remnants of blood,
marrow and fibrous tissue, but there is a danger of the bristles remaining
behind, hence it is not routinely used.
Cement Application and Pressurization

A medium or high viscosity cement is preferred to reduce the risk of blood
laminations at the interface. The surgeon must go through the registry
studies and choose the cement with good long-term results. Commercially
made antibiotic cement is preferred as the uniform distribution and ‘leech-
ing’ of antibiotic is essential.12 Timing is critical and the bone bed should
be as clean and dry as possible. Cement setting times and viscosity are
Fig. 9.6 Newer acetabular cement pressurizers for good

cementing of acetabulum.
dependent on the operating room (OR) temperature and a surgeon must

be aware of the cement behavior in his OR and must decide on applica-
tion and pressurization time accordingly. In the acetabulum, the cement is
applied en bloc, so immediate pressurization can be implemented. Usually
till socket size of 54 mm, a 40 g pack of cement is sufficient; 60–80 g packs
are needed for larger sizes (Fig. 9.6).
The cement is pressurized using the newly designed acetabulum
pressurizer, usually a size 4 mm larger than the last reamer is selected,
to act as an effective seal and avoid cement escape. Sustained pressuriza-
tion is maintained till good cement penetration and high viscosity are
reached (Fig. 9.7).
A B
Fig. 9.7 (A) Cement pressurized till doughy stage. (B) Excess cement over transverse
acetabular ligament (TAL) removed and cup inserted.
Cup Insertion
Usually a flanged, highly cross-linked polyethylene cup, of size 4 mm
smaller than the last reamer, is selected to ensure a 2 mm thick cement
mantle in all zones. Polymethyl methacrylate (PMMA) spacers in newer
designs help maintain uniformity of mantle and avoid bottoming out
of cup. The cup is then inserted using the cup holder. Initially the cup
is inserted horizontally and pushed fully medially, and then gradu-
ally inclined to the desired 45° with about 15° to 20° of anteversion.
Depending on the native femoral anteversion, the anteversion of the
cup and the femoral stem is adjusted. Cup holder is then removed and a
simple ball pressurizer is inserted to visually confirm the final position of
the cup and remove excess cement (Fig. 9.8).
Finally, all the loose cement and cementophytes are removed carefully
to avoid the risk of third body wear. Overhanging residual osteophytes are
also removed to avoid impingements and dislocations.
B C
Fig. 9.8 (A–C) Flanged highly cross-linked poly-ethylene cup
with polymethyl methacrylate (PMMA) pegs for uniform
cement mantle.
Points to Remember
1. Good pre-op planning to achieve perfect positioning of cup.
2. Meticulous bone preparation to achieve perfect cementing.
3. Selection of prosthesis and cement with good long-term track record of
longevity.
4. Use of proven and wear-resistant bearing to avoid early loosening and
revision.
5. All osteophytes and cementophytes have to be carefully removed to
avoid impingement and dislocation.
6. The long-term success of cemented acetabulum is decided by the tech-
nique of pressurization employed during the cup insertion.
Long-term results of cemented femoral components are very good, with

almost 100% survival rates at 10 year follow-up. Components have undergone
various changes over time, and today, many implant designs have achieved
near perfection with long survival records. Cementing has progressed from
early hand packing of canal to cement restrictors and retrograde pressurized
cementing using a gun. Cement itself has undergone many changes to today’s
antibiotic cement, vacuum-mixing and optimum handling time.13–16 Newer
cementing techniques help us to achieve good bony penetration of cement,
and thus achieving good mechanical interlock between bone and cement.
SURGICAL TECHNIQUE
Hypotensive anaesthesia with systolic BP < 90 mm of Hg is preferred,
which is usually achieved by spinal and/or epidural anaesthesia, to achieve
good cement preparation and avoid bleeding in the interface.
Femoral Preperation25
The hip is dislocated and the piriformis fossa identified. Femoral exposure
is usually hassle-free and can be easily done through a minimal invasive
manner. Newer and better designedretractors are very useful in good, all-
round exposure (Fig. 9.9).
B C
Fig. 9.9 (A–C) Newer femoral retractors (Courtesy: Stryker International Inc.).
The entry point should be made posterolaterally in order to facilitate the

correct direction of reaming and will ensure a well-centralized stem and a
good cement mantle all around (Fig. 9.10).
A B
C
Fig. 9.10 (A–C) Postero-lateral entry to avoid varus and centralize
the stem in canal.
Femoral Neck Cut and Head Resection

The exact osteotomy level is not critical if a collarless tapered stem design is
favored. If a collared femoral stem design is used, the neck resection should be
made according to the preoperative planning, utilizing the special instrumenta-
tion provided by the manufacturer. Resection of the femoral head is carried
out in the routine manner, approximately 1.5–2 cm above the lesser trochanter.
A relatively high neck-cut at the level of the piriformis fossa, going down at an
angle of 35° to the shaft, is considered useful as it preserves a part of the distal
neck and provides good rotational stability to the stem.
Proximal Femoral Preparation

The cortical overhang of bone from the greater trochanter is removed
with a box chisel or a curved gouge to avoid varus positioning of the
stem. Canal entry should be as posterolateral as possible. Posterolateral

canal entry ensures a central placement of stem in lateral profile to avoid
the tip of the stem from touching the anterior cortex, which may lead
to thigh pain post-op. If a stem with lateral flare is used, an osteotome
can be useful in removing the cortical bone from the medial wall of the
greater trochanter (Fig. 9.11).
A B
C D
Fig. 9.11 (A–D) Remove the medial wall of greater trochanter with box chisel or rasp it
with broach to avoid varus.
The canal is then opened with the smallest sized canal-finder. The posi-
tion should be radiologically confirmed if there is any resistance during the
progress of the reamer, or if the surgeon has any doubt about its position in
the canal. At this stage, a copious lavage is given and the medullary cavity
is meticulously aspirated, to remove as much medullary marrow as possible,
to prevent embolism during preparation and cementing.
Broaching
Broaching is then done in a serial manner with pressure application in
the posterior and lateral directions using the broach handle. Broaching is
proceeded till the template size.
In some systems, it is required to broach to a size more than the tem-

plated size, and the surgeon should be aware of this to ensure a good
cement mantle (Fig. 9.12).
C D
Fig. 9.12 (A–D) Broach till template size and check for restoration of offsets.
At the end of broaching, about 3–4 mm of cancellous bone should be

left in the anterior and medial side of the neck cut to reassure the surgeon
about correct direction and alignment of stem. Trial neck and head length
is selected to facilitate the assessment of leg length and stability.
Canal Preparation
The medullary canal is cleansed with copious pulsatile lavage. A cement-
restrictor is then inserted to about 1.5–2 cm distal to the tip of the pros-
thesis. However, now-a-days, the cement restrictors are placed at about 4–5
mm distal to the stem, as a thick cement mantle in Zone 4 may prevent
subsidence, which is deemed important for long-term survival and for pre-
vention of stress shielding (Fig. 9.13).
Usually a restrictor size of 2 mm larger than the largest olive tip that can
be passed to the isthmus is used. Modern cement restrictors are made of
A B
C
Fig. 9.13 (A–C) Cement restrictors made of polymethyl methac-
rylate (PMMA).
PMMA and bind readily with cement mantle. While the cement is being
prepared, the canal is now paced with hydrogen peroxide or norepineph-
rine packs (Fig. 9.14). (An air vent is important at this stage, as the oxygen
released from hydrogen peroxide can cause air embolism.)
Cement Mixing
The surgeon should use the cement with good long-term results in the registry
data. The surgeon should be familiar with the handling and the setting time of
the cement in his OR (for cement characteristics, refer to Ch. 20: Cementation
Techniques in Total Knee Arthroplasty – Tables 20.1 and 20.2). Both the tim-
ing and the technique of the entire cementing procedure are essential contrib-
uting factors for a successful cemented THA and long-term outcome.
Author prefers to use a low-viscosity antibiotic cement mixed under
vacuum.17 For the femur, usually 80 g of cement is used, but a stove-pipe
type canal may require up to 120 g. After having reached the preferred
B
Fig. 9.14 (A) Canal packed with a hydrogen peroxide pack.
(B) Vacuum mixing of cement.
viscosity, the cement is then rapidly applied in a retrograde fashion using a

cement-gun under pressure.
The venting tube will remove air trapped between the cement and the
restrictor. As the canal fills up, the cement shall ‘drive’ the gun out. The
nozzle is then cut short and final pressurization is done using a proximal
femoral seal (Fig. 9.15).
Usually the cement remains deficient in Zone 1, and it may be a good
habit to digitally pack the cement in this zone (Fig. 9.16).18
If pressurization is good, some bone marrow will be seen escaping the
proximal femoral cortex, and this is considered as a tell-tale sign of good
technique. The final femoral stem19–25 is inserted slowly in line with the lon-
gitudinal axis of the femur using sustained pressure (Fig. 9.17).26,27
A centralizer helps to maintain central position of the stem in the canal.
If a centralizer is used, the stem should not be inserted late as the
centralizer can cause lamination of cement mantle. The stem should
never be hammered as it may ‘break’ the cement mantle. Ideally, a good
composite cement–bone mantle of 5 mm should be seen medially at the
neck cut (Fig. 9.18).
B C D
Fig. 9.15 (A–D) Cement guns and proximal seal.
C B
Fig. 9.16 (A, B) Cement pressurization. (C) Digital pressurization
of cement in Zone 1.
C D
Fig. 9.17 (A–D) Stem inserted till templated level with surgeon’s thumb as medial
cement seal.
A B
C
Fig. 9.18 (A) Excess cement removed. (B) Trial reduction to
done to check leg length correction. (C) Trial reduction to
done to check leg length correction.
A Barack type 1 cementing ‘White Out’ should be the aim of the surgeon
every time he cements a hip (Fig. 9.19).
Points to Remember
1. Pre-op planning is critical; select the stem that gives correct offsets and
allows a good cement mantle.
2. Careful canal entry and canal preparation are important for good align-
ment.
3. Pulsatile lavage and cleaning of the canal are important in avoiding
embolism and for good cementing.
4. Use well-documented antibiotic-impregnated cement and pressurize
with cement-gun and seals.Vacuum-mix the cement, whenever possible.
5. Long-term survival of a cemented femoral stem is ensured by technique
of canal preparation and cementing employed by the surgeon.28,29
Fig. 9.19 Final goal — “White-Out”: A well-cemented hip.
Editorial Comment: The tribology (the bearing surface couple) and

the head diameter of the femur have been kept out of the purview of this
book, as it is intended for basic techniques on hip and knee arthroplasty.
This has been done for all the following chapters:
s Chapter 9: The Cemented Hip: How to Get it Right
s Chapter 10: Uncemented Total Hip Arthroplasty
s Chapter 30: Recent Advances in Short Stem Designs
The reader can refer to the references for further details.
REFERENCES
1. Aamodt A, Nordsletten L, Havelin LI, Indrekvam K, Utvag SE, Hviding K.
Documentation of hip prostheses used in Norway: a critical review of the literature
from 1996–2000. Acta Orthop Scand 2004;75(6): 663–76.
2. Havelin LI, Engesater LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The Norwegian
Arthroplasty Register: 11 years and 73,000 arthroplasties. Acta Orthop Scand
2000;71(4):337–53.
3. National Health Care. Quality Registries in Sweden 1999. Stockholm: Information
Department, The Federation of Swedish County Councils, 2000.
4. Swedish National Hip Arthroplasty Register. Annual Report, 2002. Available at:
http://www.jru.orthop.gu.se/.
5. Williams HDW, Browne G, Gie GA, Ling RSM,Timerley AJ,Wendover NA. The Exeter
cemented femoral component at 8–12 years. J Bone Joint Surg B 2002; 84B:324–34.
6. Joshi AB, Porter ML, Trail IA. Long-term results of Charnley low friction arthroplasty
in young patients. J Bone Joint Surg 1993;75-B:616–23.
7. Barrack RL, Mulroy RD, Harris WH: Improved cementing technique and femoral
component loosening in young patients with hip arthroplasty. A 12-year radiographic
follow up. J Bone Joint Surg 1992;4-B:385–89.
8. Breusch, M. The Well Cemented Hip, Theory and Practice. Springer, 2005.
9. Charnley J. The long term results of low-friction arthroplastyof the hip performed as
primary interventions. J Bone Joint Surg (Br.);1972:54-B:61–76.
10. Hodgkinson JP, Maskell AP, Paul A, Wroblewski BM. Flangedacetabular components in
cemented Charnley hip arthroplasty. Ten-year follow-up of 350 patients. J Bone Joint
Surg 1993;75-B:464–67.
11. Timperley J, Howell JR, Gie GA. Implant choice: rationale for a flanged socket, Chapter
7.6. In: The Well Cemented Total Hip Arthroplasty. Springer; 2005: 208–13.
12. Adams K, Couch l, Cierny G, Calhoun J, Mader JT. In vitro and in vivo evaluation of
antibiotic diffusion from antibiotic-impregnated polymethymethacrylate beads. Clin
Orthop 1992;278:244–52.
13. Kuhn KD. Bone Cements. Berlin, Heidelberg, New York, Tokyo: Springer, 2000.
14. Kuhn KD, Ege W, Gopp U. Acrylic bone cements: composition and properties. Orthop
Clin N Am 2005;36:17–28.
15. Kuhn KD. Handling properties of polymethacrylate bone cements. In: Walenkamp
GHIM, Murray DW, eds. Bone Cements and Cementing Technique. Berlin, Heidelberg,
New York, Tokyo: Springer, 2001.
16. Kuhn KD. Handling properties of polymethacrylate bone cements. In: Walenkamp
GHIM, Murray DW, eds. Bone Cements and Cementing Technique. Berlin, Heidelberg,
New York, Tokyo: Springer, 2001.
17. Wilkinson JM, Eveleigh R, Hamer AJ, Milne A, Miles AW, Stockely I. Effect of mixing
technique on the properties of acrylic bone cement. J Arthroplasty 2000;15:663–7.
18. Iwaki H, Scott G, Freeman MAR. The natural history and significance of radiolucent
lines at a cemented femoral interface. J Bone Joint Surg 2002;84-B:550–55.
19. Collis DK, Mohler CG. Comparison of clinical outcomes in total hip arthroplasty using
rough and polished cemented stems with essentially the same geometry. J Bone Joint Surg
Am 2002;84-A(4):586–92.
20. Crawford RW, Gie GA, Ling RSM. An 8–10 year clinical review comparing matt and
polished Exeter stems. Orthop Trans 1998;22(1):40.
21. Crawford RW, Evans M, Ling RS, Murray DW. Fluid flow around model femoral
components of differing surface finishes – In vitro investigations. Acta Orthop Scand
1999;70(6):589–95.
22. Crawford RW, et al. Fluid migration around model cemented femoral components. J
Bone Joint Surg Br 1999;81(Supp I):82.

23. Ling RSM, Hon F. The use of a collar and precoating on cemented femoral stems is
unnecessary and detrimental. Clin Orthop 1992;285:73–83.
24. Race A, Miller MA, Ayers DC, Cleary RJ, Mann KA. The influence of surface rough-
ness on stem-cement gaps. J Bone Joint Surg Br 2002; 4(8):1199–204.
25. Savilahti S, Myllyneva I, Pajamaki KJ, Lindholm TS. Survival of Lubinus straight (IP) and
curved (SP) total hip prostheses in 543 patients after 4–13 years. Arch Orthop Trauma Surg
1997;116(1–2): 10–13.
26. Breusch SJ. Cementing technique in total hip replacement: factors influencing survival
of femoral components. In: Walenkamp GHIM, Murray DW, eds. Bone and Cementing
Technique. Berlin, Heidelberg, New York, Tokyo: Springer, 2001.
27. Charity JAF, Gie GA, Hoe F, Timperley AJ, Ling RSM. The Exeter polished stem in
the long-term: a survivorship study to the 33rd year of follow-up and a study of stem
subsidence. Hip Int 2004;14:83.
28. Malchau H, Herberts P, Soderman P, Oden A. Prognosis of total hip replacement:
Update and validation of results from the Swedish National Hip Arthroplasty Registry.
67th Annual Meeting of the American Academy of Orthopaedic Surgeons, Orlando,
USA, March 15–19, 2000.
29. Malchau H, et al. Prognosis of total hip replacement – update of results and risk-ratio
analysis for revision and re-revision from the Swedish National Hip Arthroplasty Register
1979–2000. 69th Annual Meeting of the AAOS, Dallas, USA, February 13–17, 2002.
Chapter 10
Uncemented Total Hip

Arthroplasty
Vijay C. Bose, Subramanyam Yadlapalli, Ashok Kumar
INTRODUCTION
Uncemented total hip arthroplasty was introduced in early 1980s in an
attempt to address the issues of aseptic loosening and late failures associ-
ated with cemented hip arthroplasty. Cementless fixation by means of bone
ingrowth has been successful in achieving good long-term results, especially
in patients with good bone stock. It is often the choice in young and active
patients; however, older age is not an absolute contraindication. Initial
implant stability and long-term osteointegration have been proven to be
the key factors in achieving good outcome in uncemented hip arthroplasty.
ACETABULAR COMPONENT
Cemented acetabular components have demonstrated early mechanical
failure, especially in the younger age group.1,2 It is often the mechanical
failure of the bone–cement interface, which leads to these poor results.
Cementless acetabular components were designed to address the issues of
bone implant interface. The implants establish and maintain a rigid bone
implant interface that has remodelling potential such that bony intercala-
tion into the implant is re-established.
Clinically, achieving immediate implant stability at the time of surgery
is the single most important factor in the subsequent development of bone
ingrowth and long-term fixation. The immediate implant stability can be
achieved either through press-fit or polar fixation. Press-fit fixation involves
implantation of oversized acetabular component, making use of the visco-
elastic properties of the bone to allow deformation and recoil of the bone
in order to grip the implant firmly. Additional screws are used to achieve
immediate stability in polar fixation. Both these techniques rely on bone
ingrowth to achieve long-term stability.
Though the initial results of the uncemented components were poor,
Uncemented Total Hip Arthroplasty 139
better understanding of the component shape and coating surfaces sig-

nificantly improved the survival rates of the newer generation cementless
sockets. Callaghan et al. in their series have reported no loosening at 8.5
and 14 years follow up.3, 4
DESIGN CONSIDERATIONS
Initial designs of uncemented acetabular components were cone shaped
with fixation rod into the posterior column of the pelvis.5 Mittelmeier
in 1974 introduced the threaded ring designs.6 These components relied
only on mechanical interlock between the acetabular bone and the implant
threads for both initial and long-term fixation and hence had high revision
rates in long term studies.7–9 Second generation threaded cups had addition
of porous coating or grid blasting to provide bone ingrowth or ongrowth.
These cups achieved initial mechanical stability through mechanical inter-
lock and relied on biological fixation for long-term stability.
Current designs are hemispherical or modified hemispherical cups
made of commercially pure titanium or titanium-based alloy.
SURFACE AND COATINGS

Ingrowth of the component occurs when bone grows inside a porous
surface. The pore size required is between 50 and 400 mcm (microm-
eters), and the percentage of voids within the coating should be between
30% and 40% to maintain mechanical strength.10 Chromium or titanium
alloy beads, metal fiber mesh and porous material are the commonly used
ingrowth surfaces. These surfaces differ in the preparation technique. Beads
are added on to the surface at very high temperatures. Diffusion bonding
technique is used in components using fiber mesh. As the name implies,
porous metal is high porous (75% to 85%).11
Ongrowth occurs when bone grows onto a roughened surface.
These roughened surfaces are often prepared by grit blasting or plasma
spraying. In grit blasting, aluminum oxide particles are bombarded onto
the surface of the stem to create a rough surface of 3–5 mm. Plasma
spray technique involves pressurized molten material mixture of metal
and inert gas sprayed onto the component. Ongrowth surfaces maintain
90% of the fatigue strength.
Calcium phosphate compound, hydroxyapatite is also often used as
a surface coating to improve osteoconductivity into implant surface.

Concerns of interface degradation, leading to implant loosening, have been
raised with these coatings.
INDICATIONS AND CONTRAINDICATIONS

Cementless fixation is usually reserved for, though not limited to, young
active individuals with good bone quality.
Paget’s disease, tumour involvement and postirradiation might not have
good bone ingrowth potential and are not ideal candidates for cementless
fixation.
TECHNIQUE
Exposure
It is essential to ensure an unimpeded view of the entire socket all along
the circumference. Appropriate placement of the retractors is essential so
that the line of sight, in the plane
of socket orientation is free of any
obstruction. Superior pin is placed
in the ilium at 12 O’clock position,
and posterior pin is placed in the
ischium. A blunt cobra retractor is
placed over the anterior column to
displace the femur anteriorly. Two
retractors are positioned on either
side of the transverse acetabular
Fig. 10.1 (A) Anterior retractor. (B)
ligament inferior to it (Fig. 10.1). Posterosuperior pin. (C) Posterior ischial
pin. (D, E) Inferior retractors on either side
Cup Orientation of transverse acetabular ligament (TAL).
The safe zone for acetabular component placement is 10°–25° of antever-
sion and 35°–45° inclination. Transverse acetabular ligament (TAL) and
the anterior wall of the acetabulum are the common indices used for cup
orientation. After adequate exposure of the acetabulum, TAL is identified.
Any inferior osteophytes covering the TAL are removed. The anteversion
of the cup is determined by aligning it collinear to the TAL (Fig. 10.2), and
it should be in line with the anterior wall. It should be remembered that
increased anterior wall uncoverage increases the anteversion. Inclination is
determined by aligning the inferior margin of the cup to the inner margin
of the TAL (Fig. 10.3).
Socket Preparation
Fig. 10.2 Acetabular component aligned Fig. 10.3 Acetabular component aligned
parallel to transverse acetabular ligament along the inferior margin of transverse
(TAL). acetabular ligament (TAL).
This step is crucial in obtaining the initial stability of the acetabular compo-
nent. Fovea is cleared off the soft tissue to define the true medial wall. Most
of the newly available uncemented acetabular components are hemispheri-
cal and the native acetabulum is oblong. Acetabulum should be reamed to
accommodate these hemispherical components. Initially a small reamer is
used to deepen the acetabulum to the true floor. Once the true floor is identi-
fied, reaming proceeds in the direction of the native anteversion and inclina-
tion with 2 mm increment in reamer size. Once the acetabular reamer makes
excellent contact with the anterior, posterior, dome and lateral rim acetabular,
reaming has to proceed cautiously with 1 mm increment. Under-reaming of
the acetabulum depends on bone quality and the sharpness of the reamers. A
1 mm under-ream is usually sufficient in most sockets and 2 mm of under-
reaming is preferred in less dense bones. However, it might even be required
to ream the socket to the same size as the original cup. This often happens in
sclerotic bone, and it should be done with caution. Initially only the rim is
reamed and is gradually deepened depending on the fit obtained.
Special Tips for Monoblock Cups

Monoblock cups are large profile cups and most often require line-to-line
reaming. However, the reaming should be done in an extremely cautious
manner. As a first step, trailing should be done with socket under-reamed by 2
mm. In most cases, it is not enough and it will require further reaming. In the
next step, trailing is done with cup under-reamed by 1 mm. If adequate seat-
ing is not achieved, then line-to-line reaming is done, and the trail component
is inserted to check the adequacy of press fit. At times, even over-reaming by
1 mm might be required to achieve adequate seating of the component. This
is usually encountered in sclerotic sockets and should be done cautiously.
Sizing and Positioning of the Component

Trail component acetabular 1 mm larger diameter than the final reamer size
is placed in determined anteversion and inclination. It should always be kept
in mind that up to 20% of posterosuperior uncoverage of the cup is common
and must be ignored. The size of the component is confirmed if the whole
pelvis can be rocked with the trail component in situ. Once the size is con-
firmed, original component is impacted into position in the same anteversion
and inclination. In hemispherical acetabular component, rim contact occurs
before dome seating of the cup, and it requires additional impaction to ensure
adequate seating. Seating is confirmed by sighting through the apical hole or
screw holes. Acetabular screws can be placed for additional stability. Once the
acetabular component is inserted, liner is placed and femur approached.
Supplemental Fixation
Various supplemental fixation options like screws, dome spikes, peripheral
pegs and fins are available. However, screws are the most commonly used
mode of adjunctive fixation. Screws effectively convert torsional forces to
compressive forces. This preloads the bone prosthesis interface, increasing
the contact area and promoting bone growth. Lacheiwicz et al.12 showed
that greater torque was required for screw failure as compared to spikes
and pegs. Stiehl et al.13 revealed less micromotion with the use of screws
compared to fins. Indications of screw fixation:
1. Osteoporotic bones and soft bones of inflammatory arthritis with inad-
equate press fit.
2. Protrusio acetabuli requiring bone grafting.
3. Dysplastic hips.
Acetabular screws usually should lie within the safe quadrant, which
lies from the anteroinferior iliac spine to the centre of the acetabulum and
posteriorly by a line from sciatic notch to the center of the acetabulum.
Posterosuperior quadrant is often the safe zone.
FEMORAL COMPONENT
Excellent long-term clinical and radiological outcomes of uncemented femo-
ral component have been reported by many authors.14–16 Good osseous inte-
gration without fibrous tissue intervention is required for these good results.
Micromotion of <20 mm at bone implant interface is essential for bone
formation. Motion of >150 mm leads to fibrous tissue formation, between 40
and 150 mm leads to a combination of bone and fibrous tissue formation.17,18
Initially designed uncemented femoral components had poor results in
terms of longevity. Austin Moore was the first to demonstrate the possibil-
ity of biologic fixation in the femoral component.19 Intensive experimental
research on surface coatings and tissue ingrowth in 1970s revealed basic
criteria and paved the way for uncemented implants. They emphasized the
importance of pore size (50–500 mcm) and stable implant with minimal
microinterface motion. Initially, fully porous coated femoral component
was designed and later it underwent modifications with regard to size,
surface coating, etc. Stem with porous coating on >80% of surface is often
considered extensively porous coated. Forty per cent porosity has been
considered optimal for balancing strength of the porous coating substrate
interface and that of porous coating bone interface.
The first designs of uncemented femoral components were cylindri-
cal, with extensive porous coating. These stems had good fixation but
had issues with cortical atrophy, proximal stress shielding and bone loss.
These stems were improvised and philosophy of metaphyseal fixation was
developed to naturally load the femur. Press fit stems were initially devel-
oped by Judet. Later calcar supporting and wedge fit stems were devel-
oped. Main concern with these stems was sizing and ability to achieve
press-fit due to varied proximal femoral anatomy. Increasing the num-
ber of sizing options addressed this issue. These implants can be either
metaphyseal or diaphyseal fit. Principally, a femoral prosthesis should be
fixed as proximal as possible to prevent stress shielding. However, signifi-
cant proximal femur deficiency necessitates distal fixation. Irrespective of
these, uncemented femoral components rely on firm mechanical initial
fixation of the implant to the bone.
Proximal Femoral Geometry

Assessment of the proximal femoral geometry is essential in planning an unce-
mented total hip arthroplasty. Dossick et al. classified proximal femur based on
calcar to canal ratio (Fig. 10.4).20 The outer diameter of the femur at the mid
portion of lesser trochanter is divided by the diameter at a point 10 cm distal.
Fig. 10.4 Dossick calcar to canal ratio - a/b.
s 4YPE!Ratio < 0.5

s 4YPE"Ratio 0.5–0.75
s 4YPE#Ratio >0.75
Type A femur has good cortices in both views. Type B femur has thinning
of posterior cortex on lateral view. Type C is a typical stovepipe type femur
with thinning of cortices on both views. Type A is generally believed to be
appropriate for uncemented femoral component. Type B bone is intermedi-
ate, and cemented component use is generally preferable in Type C femurs.
Factors That Influence the Primary Fixation of Femoral

Component
1. Roughness and coating of the stem
2. Stem geometry
3. Technique of preparation
4. Bone quality
SURFACE AND COATINGS

Surface and coatings of femoral components are similar to uncemented
acetabular components. Common issues with uncemented femoral com-
ponents like thigh pain and proximal stress shielding are better addressed
with materials that have elastic properties closer to that of normal bone.
This makes stems made of titanium alloys a better choice than that of
cobalt–chromium alloys.21,22 Thigh pain, however, is believed to result also
from the stem geometry.
STEM GEOMETRY
1. 7EDGE DESIGNS In these designs, fixation is in the proximal femoral
metaphyseal bone. They have integrating surface limited to the proxi-
mal part of the stem and they taper distally. There are two types of
wedge designs based on their fit in the proximal femur. Single wedge
type of stems engage primarily the mediolateral plane. Double wedge
stems engage both the mediolateral and the anteroposterior surfaces
2. 4APEREDDESIGNSThese designs have long, consistent taper in both the
mediolateral and the anterior–posterior plane. Unlike wedge designs,
there is no abrupt change in geometry or coating, and fixation is obtained
more at the metaphyseal–diaphyseal junction than in the metaphysis.
3 &ULLY COATED CYLINDRICAL DESIGNS These stems have integration
surface all along the prosthesis. Their fixation is primarily diaphyseal.
Some of these stems have a collar, which is designed to load the calcar
of the proximal femur.
4 -ODULARDESIGNSThese stems are often used in patients with abnor-
mal proximal femoral geometry. They are primarily proximal metaphy-
seal integrating stems. Additional stability can be achieved through
diaphyseal fixation. It requires appropriate preparation of both the
proximal and distal femur.
TECHNIQUE
Femoral Neck Resection
After dislocation of the head, initial neck cut is made at the level of base of
the head for easy retraction during exposure of the acetabulum. Once the
acetabular component placement is completed, the leg is internally rotated
and the neck is exposed with a spike under the femoral neck. The remnant
of pyriform is removed to expose the pyriform fossa. Initial cut is made along
the medial border of the greater trochanter in line with the intertrochanteric
crest.This facilitates desired appropriate lateral entry.The neck is then osteoto-
mized at predetermined level, with the thigh parallel to the ground to avoid
uneven anteroposterior cut.
Femoral Preparation and Component Placement

Adequate preparation of the canal is the key for component stability.
Initially, a box chisel is used to remove the lateral bone and facilitate appro-
priate entry. Medial entry point in the neck results in a varus positioning
of the component (Fig. 10.5).
Fig. 10.5 Varus positioning of the compo-

nent following medial entry point.
The main concern with varus positioning would be undersizing of
the femur component, resulting in early subsidence. The chiselled bone is
compacted into the proximal metaphysis with a bone tamp to preserve the
cancellous bone (Fig. 10.6).
Then a canal identifier is passed and femoral canal is identified. Femoral
broaching is started with the smallest broach and gradually increased till
adequate rotational stability is achieved. Anteversion of the femoral compo-
nent is determined by placing the broach parallel to the posterior cortex of
the femoral neck (Fig. 10.7).
Fig. 10.6 Cancellous bone compaction Fig. 10.7 Femoral component aligned paral-
with bone tamp. lel to posterior cortex of the femoral neck.
This often gives the desired anteversion in most cases. Trail reduction is
done with an undersized trail. Three key factors contributing to balancing
of the hip are assessed.
1. Combined anteversion
2. Impingement
3. Limb length
If additional neck cut, offset or anteversion adjustment is required to
achieve appropriate limb length, hip balance and combined anteversion, it
is done at this point. It should be remembered that the anteversion with
a nonmodular metaphyseal filling stems can only be adjusted by 5°–10°.
Once the above three factors are adequately restored, the stem is checked
for rotational stability. This is done with the leg held in internal rotation
and the assistant holding the stockinet of the leg. The trail is moved clock-
wise and anticlockwise, checking for implant bone interface mobility. If the
stem is rotationally stable, the whole leg should move as a single unit when
held and moved with the implant. Once the size is determined, original
component is placed and the head is reduced.
Closure
The leg is repositioned in abduction and neutral or slight external rotation
and capsule-to-capsule closure is done with ethibond. This is followed by
suturing of the external rotators and the rest of the posterior soft issues.
POSTOPERATIVE PROTOCOL
Patients start weight bearing and physical therapy the same day. They are
followed up at 2 weeks, 6 months, and then 2 yearly thereafter.
REFERENCES
1. Dorr LD, Luckett M, Conaty JP. Total hip arthroplasties in patients younger than 45
years: a nine to ten year follow up study. Clin Orthop 1990;(260):215–19.
2. Cornell CN, Ranawat CS. Survivorship analysis of total hip replacements: results in a
series of active patients who were less than fifty-five years old. J Bone Joint Surg AM.
1986;68(9):1430–34.
3. Callaghan JJ, Tooma GS, Olejniczak JP, et al. Primary hybrid total hip arthroplasty: an
interim follow up. Clin Orthop 1996;333:118–25.
4. Callaghan JJ, Gaffey JL, Goetz DD, et al. Cementless acetabular fixation at 15 years with
HG 1 cup: comparison to the gold standard Charnley. Paper presented at American
Association of Hip and Knee surgeons 12th Annual meeting, Dallas, TX, 2002.
5. Ring PA, Ring UPM. total hip arthroplasty. Clin Orthop 1983;176:115–23.
6. Mittelmeier H. Report on the first decennium of clinical experience with a cementless
ceramic total hip arthroplasty. Acta Orthop Belg 1985;51:367–76.
7. Bruijn JD, Seelen JL, Feenstra R, et al. Failure of the mercring screw-ring acetabular
component in total hip arthroplasty. J Bone Joint Surgery. 1995;7A:760–66.
8. Fox GM, Mc Beath AA, Heiner JP. Hip replacement with a threaded acetabular cup: a
follow up study. J Bone Joint Surgery 1994;76A:195–201.
9. Pupparo F, Engh CA. Comparison of porous-threaded and smooth-threaded acetabular
components of identical designs: two to four year results. Clin Orthop 1991; 271:201–06.
10. Bobyn JD, Pilliar RM, Cameroon HM, et al. The optimum pore size for fixation of
porous-surface metal implants by the ingrowth of bone. Clin Orthop 1980; 298:27.
11. Engh CA, Bobyn JD, Glassman AH. Porous coated hip replacement. J Bone Joint Surgery
1987;69B:44–55.
12. Lachiewicz PF, Suh PB, Gilbert JA. In vitro initial fixation of porous-coated ace-
tabular total hip components. A biomechanical comparative study. J Arthroplasty
1989;4(3):201–5.
13. Stiehl JB, MacMillan E, Skrade DA. Mechanical stability of porous-coated acetabular
components in total hip arthroplasty. J Arthroplasty 1991;6(4):295–300.
14. Archibeck MJ, Berger RA, Jacobs JJ, et al. Second generation cementless total hip
arthroplasty: eight to eleven year results. J Bone Joint Surg 2001;83A:1666–73.
15. Capello WN, D’Antonio JA, Feinberg JR, et al. Ten year results with hydroxyapatite
components in patients less than fifty years old. J Bone Joint Surg 2003;85A:885–89.
16. Sinha Rk, Dungy DS, Yeon HB. Primary total hip arthroplasty with proximally coated
stem. J Bone Joint Surg 2004;86-A(6):1254–61.
17. Jasty M, Bragdon C, Bruke D, et al. In vivo skeletal responses to porous –surfaced
implants subjected to small induced motions. J Bone Joint Surg 1997;79A:707–14.
18. Pilliar RM, Lee JM, Maniatopoulos C. Observations on the effect of movement on
bone growth into porous-surfaced implants. Clin Orthop 1986:208:108–13.
19. Moore AT. A metal hip joint: a new self-locking Vitallium prosthesis South. Med J
1952;45:1015–19.
20. Dossick PH, Dorr LD, Gruen T, et al. Technique of pre operative planning and post
operative evaluation of non cemented hip arthroplasty. Techniques Orthop 1991;6:1–6.
21. Marshall AD, Mokris JG, Reitmanr D, Dandar A, Mauerhan DR. Cementless titanium
tapered-wedge femoral stem: 10–15 year follow up. J Arthroplasty 2004;19(5):546–52.
22. Bourne RB, Rorabeck CH, Patterson JJ, Guerin J. Tapered titanium cementless total
hip replacements: a 10- to 13 year follow up study. Clin Orthop 2001;393:112–20.
Chapter 11
Total Hip Arthroplasty in

Peritrochanteric Fractures
C. J. Thakkar
Fractures of trochanteric region of femur are common in elderly. Internal

fixation of these fractures is a standard practice. Replacement with either
bipolar or total hip is considered mainly for failed fixation. In fresh com-
minuted fracture through porotic bone in elderly with medical comor-
bidities, replacement may be preferred to allow early full weight bearing
mobilization.1 Technical challenges on the operating room (OR) table
include selection of prosthesis, equalization of limb length, management of
trochanter and prevention of dislocation.
According to our experiences, patients of intertrochanteric fractures
with good bone stock and stable fracture configuration with no associ-
ated comorbidities are candidates for internal fixation. On the other hand,
patients with poor bone stock (osteoporosis) and/or unstable fracture
configuration and/or significant comorbid conditions, which require early
mobilization and are associated with high risk for revision surgery, are can-
didates for replacement surgery.2,3
The choice of femoral implant is based on the life expectancy of the
patient and the quality of the remaining bone.4,5 Usually these patients
are more fit than the patients in whom primary hip replacement is done.
Noncemented calcar replacement, diaphyseal fit revision prosthesis may be
the first choice, since one needs to build up the supratrochanteric length
and also needs to have an implant that goes the distance of two canal width,
distal to the last screw hole in order to prevent stress fracture in the post-
operative period.
When one considers replacement for trochanteric fractures that had
previous fixation device in place, one needs to consider the mode of failure
of fixation. In majority of cases, the fracture collapses in varus, resulting in
cutting out of the implant in the head in superior and anterior direction.
The tip of the head implant may or may not damage the acetabulum. If
the acetabular articular surface is not damaged, one may consider bipolar
replacement, else total hip would become an obvious choice.
There may be instances when the failure involves breakage of fixation

device itself, like broken screw through the shaft or broken intramedullary
device. In these situations, one is faced with the challenge of removal of
broken implant that may need special instruments.
FRESH FRACTURES
Replacement is considered mainly for multifragmentary fractures, especially
when there is posterior comminution either posteromedial due to the sepa-
ration of lesser trochanter or posterolateral due to comminution of greater
trochanter. In either situation, there is lack of bony support to the proximal
part of the prosthesis. This may require either calcar replacement prosthesis
or building up of the proximal femur either by cement or bone graft.
Distortion of proximal anatomy causes difficulty in assessment of ver-
sion and limb length equalization. Fixation of abductor mechanism to the
prosthesis is another challenge, as the trochanteric piece is either porotic or
comminuted posing difficulty in fixation.
APPROACH
The greater trochanteric split is used for direct approach to the proxi-
mal femur, preserving the soft tissue attachment and vascularity of its
pieces. The anterior fragment with its attached glutei and vastus lateralis is
retracted anteriorly. Due to its digastric attachment, proximal migration of
trochanteric piece is prevented. The posterior fragment with its attached
short external rotators is retracted posteriorly. This exposes the neck of the
proximal fragment end on.
Excision of the proximal fragment consisting of head and neck of
femur is not as easy as in the case of subcapital fracture, because of the
capsular attachment to the proximal fragment, which requires radial cap-
sulotomy. Corkscrew femoral head extractor is introduced through the
exposed neck, into the femoral head, helping maneuvers to remove the
proximal fragment.
Unless the hip is arthritic, bipolar replacement is preferred. Since most
of these patients are elderly with wide medullary canal and limited life
expectancy, we prefer cemented femoral implant. If the lesser trochanter
piece is large, it may be prudent to attach it to the shaft fragment using
cerclage wire to build proximal bone stock.
Total Hip Arthroplasty in Peritrochanteric Fractures 151
At this stage, one faces the challenge of absence of calcar, which in neck
fracture helps in supporting proximal portion of femoral prosthesis and in
maintaining correct version. To overcome this problem, we harvest graft
from the femoral head and wedge it between the medial femoral cortex
and the prosthesis (Figs 11.1–11.6). This technique helps in building the
Fig. 11.1 Bone graft harvested from medi- Fig. 11.2 Graft wedged between the rasp
al neck and head. and medial femoral cortex, supporting
proximal portion of the rasp.
Fig. 11.3 Bone model depicting intertro- Fig. 11.4 Area of head and neck from
chanteric fracture. where the graft is harvested.
Fig. 11.5 Graft wedged in the medial void.
A B
Fig. 11.6 Graft–prosthesis composite.
missing proximal bone, and prevents varus and retroversion by supporting

the prosthesis medially. In the absence of calcar, the prosthesis would be
inserted deeper than when the calcar is present, resulting in shortening of
the limb. This graft replaces the missing calcar and when the prosthesis
is then inserted and its proximal edge rests on the proximal edge of the
graft, the limb length equalization is achieved (Fig. 11.7).
Fig. 11.7 Graft wedged between medial femoral cortex

and medial edge of prosthesis, supporting upper end of
the prosthesis.
Since majority of the patients are old with wide osteoporotic canals,
the prosthesis is cemented, hence the load is shared by the femoral diaph-
ysis, and the graft then does not fail.
Trochanteric pieces are then wired to each other and to the shaft
in standard fashion. Though trochanteric nonunion is known to occur,
but since the trochanteric pieces have digastric attachment, they do not
migrate proximally and the abductor lurch is minimal.
FAILED FRACTURES WITH IMPLANT IN SITU

One may encounter either intra-medullary or extra-medullary implants.
The common mode of failure is varus of the proximal fragment, leading to
anterosuperior cut out of the implant through the femoral head. Rarely there
may be instance of breakage of screws or the nail or the plate (Fig. 11.8).
A B
Fig. 11.8 Total hip replacement (THR) for failed IT fracture.
Our preferred approach is posterior, detaching the short external rotators

from the trochanter and dislocating the hip by internal rotation and adduction.
It is prudent to dislocate the hip before removing the implants, because if the
implants are removed first, then the screw holes may act as stress riser, and there
is a possibility of creating a fracture through weak osteoporotic bone. It is also
advisable to put minimum two cerclage wires around the diaphysis, one distal
to the last screw hole and one proximal, to prevent splitting of the shaft while
rasping the medullary canal.
In majority of cases, there is fibrous union between the head neck frag-
ment and trochanteric and shaft fragments. A large void is left at the base
of the trochanter on removal of head fixing screw. This site is another weak
point, which may result in the separation of trochanter from the shaft while
inserting the implant. It is better to wire the trochanter to the shaft, else if
it separates in the postoperative period, it may lead to proximal migration
of the trochanter and hip dislocation due to unopposed force of adductors
or residual abductor lurch.
Postoperative rehabilitation is aimed at rapid upright position to
prevent complications of recumbency in this elderly group of patients.
Support walking with tolerated weight bearing is started as early as pos-
sible. Routine hip mobilization protocols are followed unless there is some
contraindication to the same.
REFERENCES
1. Kayali C, Agus H, Sanli C- J. Treatment for unstable intertrochantric fractures in elderly
: Internal fixation v/s cone hemiarthroplasty. Orthop Surg (Hong Kong) 2006;14(3);240–4.
2. Harwin SF, Kulick RG. Primary bateman–leinbach bipolar prosthetic replacement
of hip in treatment of unstable intertrochantric fractures in elderly. Orthopaedics
2009;13(10):1131–36.
3. Pho RW, Nather A, Tong GO, Korku. Endoprosthetic replacement of unstable, com-
minuted intertrochantric fracture of femur in the elderly, osteoporotic patient. J Trauma
1981; 21(9): 792–97.
4. Broos PL, Rommens PM, Deleyn PR, Geens VR, Stappaerts KH. Pertrochanteric frac-
tures in the elderly: are there indications for primary prosthetic replacement? J Orthop
Trauma 1991;5(4):446–51.
5. Haentjens P, Casteleyn P P, De Boeck H, Handelberg F, Opdecam P. Treatment of unsta-
ble intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar
arthroplasty compared with internal fixation. J Bone Joint Surg Am 1989;71(8):1214–25.
Chapter 12
Fused Hips in Ankylosing

Spondylitis
Pradeep B. Bhosale, Prabodhan P. Potdar
INTRODUCTION
Ankylosing spondylitis (AS) is a medical disease of young adults with bony
complications relating to spontaneous joint fusion over a period of time.
India has a prevalence of 0.06%, the disease being of juvenile onset with
peripheral symptoms of enthesitis and peripheral arthritis developing ear-
lier than axial symptoms.1 Most commonly affected joints are sacroiliac
joints, facet joints, hips, knees and ankles. AS has been traditionally linked
with spondyloarthritides associated with HLA B27 allele. About 90% of
AS patients have positive reaction on HLA B27 testing. However, the HLA
association is not correlated to severity of the disease. Males have a 3:1 pre-
dominance over females and are affected in the second or third decade of life.
Median age of presentation in western countries is approximately 23 years.
Hereditary factors play a role with a concordance rate in identical twins of
65%. Immunological factors have also been implicated in the pathogenesis of
AS. AS can be clinically diagnosed by the modified New York criteria set in
1992 with documented sacroilitis being the major criteria.2
Of all the cases of AS, about 24–36% have hip involvement. The role of
total hip arthroplasty (THA) in AS is in the arthritis stage. The joint may
have a jog of movement or may present with variable grades of ankylosis.
Though hip replacement follows similar protocol as other etiologies with
unfused hips, the surgical procedure for fused hips needs to be modulated
according to the deformity. The management of ankylosed hips in AS has
improvised over period of time with the use of better implants, newer sur-
gical techniques and imaging tools.3–5
MEDICAL DISEASE AND MANAGEMENT

Though an ankylosed joint is the sequelae of AS process, the medical
abnormality is still ongoing and a thorough control is necessary to prevent
Fused Hips in Ankylosing Spondylitis 157
further joint deterioration in rest of the body. A multidisciplinary approach,

coordinated by rheumatologist, adjusted to individual patient profile, which
includes nonpharmacological and pharmacological treatment modalities is
recommended for the optimal management.3,6
AS has been traditionally treated with anti-inflammatory drugs and
disease modifying anti-rheumatic drugs (DMARDs). The introduction of
newer anti-rheumatic drugs like TNF-Ơ inhibitors is effective in retarding
the progression to the stage of spontaneous fusion.7
Tips and Pearls

s 0 ATIENT MAY BE ON ANTI INFLAMMATORY DRUGS STEROIDS $-!2$S SUCH AS
methotrexate or TNF-Ơ antagonists. The appropriate use of perioperative
dosages is imperative for surgical recovery and prevention of complications.
s ) NFLAMMATORY PARAMETERS MAY BE ELEVATED IN PATIENTS WITH!3 DUE TO
inflammatory process and may not conclude preoperative infection.
ALTERED ANATOMY
AS affects all synovial joints of the body with predominance of axial
skeleton. The lumbosacral spine is affected very early on. In the spine,
zygapophyseal joints get involved, primarily leading to progressive fusion
from caudal to cranial direction. The flattening of lumbar spine due to
lumbar spine fusion and fusion of the sacroiliac joints leads to loss of
compensatory mechanisms. Of the major joints, hip involvement is early.
The hip may be mobile at first with synovitis. If untreated, there is a rapid
progression to frank ankylosis in more than 90% of cases, within a period
of 2–5 years. Sometimes the hips
may be ankylosed in flexion result-
ing in ‘pseudo-kyphotic’ deformity
(Fig. 12.1). Involvement of cervico-
thoracic spine leads to true kyphotic
deformities in the cervico-thoracic
region. In majority of cases, there is
a positive sagittal vertical axis (SVA)
and anterior shift of the center of
gravity. Subsequently, flexion of the
knees and dorsiflexion of the ankles
develop. Most of the cases with
Fig. 12.1 Frontal and side profile of patient
with ankylosing spondylitis. bilateral hip ankylosis may be able
to ambulate using their knees and ankles. However, these joints become
fixed over a period of time, resulting in complete immobility and patient is
bedridden. Restoration of the abnormal sagittal and coronal balance of the
body takes precedence in surgical treatment of AS.
CLINICAL EXAMINATION
3TIFFNESSISTHEMAJORCOMPLAINTIN!30AUCITYOFMOVEMENTINTHEHIPCANBE
DUETOINFLAMMATORYSPASMORCOMPLETETRABECULARBONYCONTINUITY0ATIENTS
may present with varied deformities of abduction, adduction, flexion or a
combination of these. The need to evaluate true and apparent shortening can-
not be overemphasized. Also evaluation of the spine may demonstrate a fixed
pelvic obliquity, which would eventually require the tweaking of inclination
of the acetabular cup. Shifting of the center of gravity due to lumbosacral
fusion may need special attention to cup placement as regards anteversion.
Knee range of motion (ROM) and flexion deformity need to be determined
preoperatively for placing the stem in adequate anteversion. The findings of
clinical examinations need to be confirmed with radiological findings.
Tips and Pearls

s +NOWTHETRUEANDAPPARENTSHORTENING
s +NOWTHESTATUSOFOTHERLOWERLIMBJOINTSESPECIALLYREGARDINGFLEXION
deformity and ROM.
s +NOWTHESTATUSOFTHESPINEREGARDINGCORONALANDSAGITTALPLANEDEFORMITY
s $EFORMITIESAREBETTEREVALUATEDCLINICALLYRATHERTHANRADIOLOGICALLY
Radiological Investigations
An anteroposterior and lateral radiograph of the hip would be the basic
investigation (Fig. 12.2). The following features need to be specifically
looked out for.
1. Magnitude of deformity and quality of bony fusion.
2. Abduction and adduction angles of the limbs.
0ROTRUSIOACETABULInINVARIABLEPRESENTINOFTHECASESOFCOMPLETE
fusion.
4. Femoral canal diameters in anteroposterior and lateral views.
5. Sacroiliac (SI) joint fusion and pelvis rotation in coronal and
sagittal planes.
6. Osteopenia
Fig. 12.2 Anteroposterior and lateral radiographs of pelvis with both hips.
Sometimes lateral radiographs may be difficult to obtain due to bony

fusion and inability to abduct the limbs. A computer tomography (CT)
scan may be helpful in these cases. Radiographs of the lumbosacral spine
would confirm fixed pelvic obliquity and status of the sacral slope. A neck
to foot scannogram may be done, to evaluate the true extent of the pelvic
obliquity and pelvic inclination. C7 plumb lines drawn on coronal and
sagittal views can help us evaluate the true extent of deformity of the spine
in coronal and sagittal views. The placement of the cup depends entirely
on maintaining the inclination and anteversion with respect to the plumb
line and is independent of the position of the hip deformity.
Computer Tomography
A CT scan is needed for further evaluation and standardization of the
radiological investigation. It also helps to determine the existing bone stock
in the acetabular floor and medullary canal diameters for stem placement.
Use of CT can be invaluable in studying the anteversion of the femoral
neck and preoperatively decide on the choice of modular implants if
required. The trabecular continuity is well seen on a CT scan. In cases of
protrusio acetabuli, coronal CT cuts gives an idea about medial acetabular
bone stock. We would recommend the use of a CT scan in difficult defor-
mities of the hip and acetabulum.
Preoperative Radiological Templating

Radiological templating is important in difficult primary hip arthroplasty.
The center of head and acetabular cup may be accurately templated in a
few cases. However, radiological templating may not be helpful in choice
of a stem, and the type of canal may not dictate the choice of implant. A
radiological Dorr C canal may just allow the smallest uncemented stem.
The decision to implant a cemented or cementless implant is pending on
intraoperative assessment of bone quality. Templating may be useful in a
few cases where proximal femoral morphology may change implant selec-
tion and positioning, requiring the use of specialized modular implants.
Tips and Pearls

s 2 ADIOLOGICAL FEMORAL CANAL DIAMETERS ARE DECEPTIVE AND INTRAOPERATIVE
assessment is recommended.
s 2OTATIONINTHEPELVISMAYNOTALLOWACCURATERADIOLOGICALTEMPLATING
In most cases, radiological templating may be erroneous.
PREANAESTHETIC ASSESSMENTS8
Spine fusion is invariably present in patients with an ankylosed hip. The
cervical spine fusion can make neck extension difficult, and the arthritis
of the crico-aryetenoid joint can further compromise the passage of the
endotracheal tube. Awake fiber-optic intubation is used world over for the
passage of endotracheal tube in AS. Tracheostomy is not required even
in difficult cases. General anaesthesia is the anaesthesia of choice. At our
center, we have been successful in using regional (spinal with epidural)
anaesthesia with fiber optic intubation kept as standby. Regional anaes-
thesia is possible since the ligamentum flavum is unaffected by the disease
process. It is essential to be prepared for general anaesthesia in case regional
anaesthesia is not possible. Decrease in tidal volume due to decreased chest
expansion is a negative prognostic factor for general anaesthesia and intuba-
TION0ULMONARYFUNCTIONTESTSSHOULDBEDONEBEFORETHEPROCEDURE5PTO
30% of these patients may develop an A–V block or right bundle branch
block (RBBB). An ECG with echocardiography is necessary to rule out
the same.9
POSITIONING OF THE PATIENT

Deformities occur in various positions of the hip. External rotational,
abduction and flexion deformities are the most commonly seen deformi-
ties at our center. Bilateral abduction deformities are not uncommon. At
our center, we prefer the lateral decubitus position with anterior pubic and
posterior sacral supports. In cases where the spine is fused, the preopera-
tive radiological coronal deviation would give us a clue regarding patient

placement. In cases of bilateral abduction, deformity padded cushions may
be placed below the dependent iliac crest and trunk to facilitate horizontal
placement of the patient (Fig. 12.3). Sometimes a ‘wind-swept’ deformity
is encountered, and we usually do the hip, which is fixed in abduction first.
Tips and Pearls

s , ATERALRECUMBENTPOSITIONGIVENWITHCARETOSUPPORTTHECONTRALATERAL
limb from iatrogenic fractures.
s 0ADDINGOFTHEDEPENDENTLIMBFROMPRESSURESORESANDPERONEALNERVE
palsy.
s (EADSUPPORTSRINGTOPREVENTFRACTURESINTHESTIFFNECK
THE APPROACH
Hip joint in AS may be mobile or stiff with variable grades of ankylosis.
Hip replacement in former cases follows similar protocol as any other THA.
Hip joint THA in ankylosed cases requires addressing the following issues.
1. Safe clean-cut neck osteotomy without bone splintering.
0REVENTIONOFDAMAGETOTHEABDUCTORSANDACETABULARWALLS
3. Restoration of biomechanics of the hip.
4. Restoration of center of rotation of the acetabular cup and head
(addressing protusio).
5. Identification of true acetabulum and preserve bone stock.
Fig. 12.3 Patient positioning and endotracheal intubation in patient with fixed hip
abduction deformity in ankylosing spondylitis.
Complete visualization of neck and soft tissue releases has been the crux
for performing THA in ankylosed hips. This becomes technically difficult
since majority of deformities are in abduction, external rotation and flexion.
The posterior structures, viz., posterior capsule and external rotators are
contracted, resulting in the inability to permit internal rotation. Also, flexion
deformity puts the sciatic nerve at direct risk for injury. Various approaches
have been used to access these difficult hips. The trans-trochanteric approach
has been widely adopted over past three decades. Though we get a 360°
exposure of the acetabulum, there are inherent complications relating to
trochanteric nonunion and gait disturbances due to altered biomechanics
of the hip.1,10 Similarly, anterior approaches are easy for external rotation
deformities. However, there are inherent problems of femur retraction due to
osteopenic bone and contracted soft tissues. Also it is not possible to release
the posterior capsule and external rotator from anterior approach. Most
importantly, cutting the neck without visual confirmation can cause the cut
to osteotomize the posterior acetabular wall. The posterior approaches are
more difficult for such hips. In externally rotated extremity, the sciatic nerve
is very close to the neck-posterior acetabular wall junction, and exposure to
the posterior aspect of neck is limited. Overzealous retraction during expo-
sure and while taking the neck-cut may cause inadvertent injury to sciatic
nerve and damage to the anterior acetabular wall. Lastly, another widely used
approach, the trans-gluteal lateral approach can cause abductor loss and supe-
rior gluteal nerve injuries.2,11 For the past 25 years, we have been approaching
these specific stiff and ankylosed hips with external rotation deformities using
a single incision dual anterior and posterior approach. This is a ‘safe neck
resection’ and ‘glutei-sparing’ approach. The approach has been perfected on
cadavers before its practical use. The approach gives complete anterior and
posterior access to the neck and safe postosteotomy maneuvering of the hip.
SURGICAL PROCEDURE
The surgical skin incision is a posterior curvilinear vertical incision centered
over the greater trochanter around 15–20 cm in length (Fig. 12.4). The ten-
sor fascia lata is cut and retracted anteriorly and posteriorly so as to gain a
generous exposure. The gluteus maximus is split and widely opened. The
anterior part of the exposure is commenced. The patient is tilted towards
the surgeon by 15°–20°. Dissection is carried out below the anterior cut
margins of the tensor fascia lata, which is retracted anteriorly with a right-
angled retractor. The dissection starts in the internervous plane between
Fig. 12.4 Surgical incision (red line) and bony prominences (red dot).
Fig. 12.5 Anterior exposure to the hip and retraction of muscles, viz., gluteus medius
(GM) , vastus lateralis (VL) and rectus femoris (RF).
the gluteus medius–minimus complex and vastus lateralis (Fig. 12.5). The
‘V’-shaped interval between the two muscles is opened after cutting the
connecting soft tissue sleeve. This exposes the gluteus minimus along with
the anterior hip capsule. The gluteus medius along with the minimus is
retracted superiorly with a Hohmann retractor positioned over the superior
part of the hip capsule. Similarly, the vastus lateralis is retracted inferiorly
with a Hohmann retractor between it and the inferior hip capsule. Anterior
longitudinal capsulotomy is performed and Hohmann retractors are repo-
sitioned over superior and inferior aspect of the neck. Medial subcapsular
periosteal dissection is performed and another pointed Hohmann retractor
is placed medial to the anterior acetabular wall. Retracting superiorly, infe-
riorly and medially exposes the fusion mass containing the head, neck and
the acetabulum. Alternatively, a smooth 3 mm Steinmann pin can be driven
into the head of the femur to act as a medial retractor. This completes the
neck exposure and we can have a complete visual and tactile feel of the
neck in all directions.
NECKCUT
With neck being completely visible and soft tissues protected, osteotomy
trajectories can be easily established using visual and tactile orienta-
tion of the neck (Fig. 12.6). A 5–10 mm sandwich cut may be taken
to prevent any iatrogenic fractures
during osteotomy. We start by
feeling the anterior and posterior
aspects of the neck and establish
the trajectory. Then we perform
the sandwich osteotomy entirely
from the anterior to posterior along
the proposed trajectory. The oste-
otomy should be clean cut and
performed under direct vision with
a sharp oscillating saw. Osteotome
should be avoided to complete
the cut as this may create fracture.
However, osteotomes may be used
to confirm the gap created. The
sandwich bone is removed with a
Fig. 12.6 Neck-cut through anterior
narrow Roungeur. This completes
approach of the dual incision. Muscles in
the picture – gluteus medius (GM), vastus the neck-cut. Utmost care should
lateralis (VL) and rectus femoris (RF). be taken to avoid any maneuvering
of the limb until the neck is com-
pletely osteotomized and there is a visible discontinuity. Even after the
complete osteotomy, the tissues surrounding may be too tight to permit
movements of internal rotation. The osteotomy gives considerable free-
dom to rotate the limb internally, which aids visualization of external

rotators and posterior capsule. The rest of the procedure proceeds like the
classical posterior approach THA.
POSTERIOR EXPOSURE
The patient is tilted 15°–20° away from the surgeon. The hip is placed in
extension and internal rotation. The trochanteric bursa is taken away and
the gluteus medius is retracted anteriorly with a pointed Hohmann retractor.
External rotators along with the posterior capsule are erased from the bone
starting superiorly from the piriformis and ending at the insertion of the
quadratus femoris caudally. We often prefer to cut the insertion of the gluteus
maximus, which is attached to the superior aspect of linea aspera as a thick
flat tendon. This has two advantages. First, the traction on the posteriorly
placed sciatic nerve decreases. Second, the anterior retraction of the femur
for acetabular reaming becomes easy. There is a perforator vessel invariably
present below the tendon, which may need to be cauterized. Care has to be
taken to safely isolate or safeguard the sciatic nerve during the entire proce-
dure. The hip is internally rotated. The internal rotation needs to be succes-
sively increased by releasing tight structures like the anterior hip capsule on
femur and psoas muscle insertion. The anterior swan neck retractor should
rest without undue traction on the anterior acetabular wall.
FEMORAL REAMING AND STEM PLACEMENT

Femoral anteversion during cementless fixation is variable and may range
from 17° retroversion to 30° anteversion.3,6,12 Approaching the femur first
gives idea about the femoral anteversion and subsequently acetabular ante-
version. Reaming may be commenced with successive metal reamers and
broaches so as to get the best fit possible. Most of the patients are young and
a cementless implant is preferred. During the use of cementless stems, care
should be taken to preserve as much cancellous bone as possible. Inadvertent
reaming can be dealt by packing cancellous bone chips at site of loss. During
trail stem insertion, care should be taken to hold the leg steady and insert
the trial patiently, to prevent intraoperative fractures. Cemented fixation
may be required for Dorr C canals and should always be kept on standby.
Reaming and determination of the native anteversion would give a clue to
the acetabular anteversion using various equations like those proposed by
Widmer and Zurfluh or Ranawat.7,13,14 There have been reports of anterior

dislocation in a few papers and the reasons are still unknown. However, an
exaggerated femoral anteversion due to the inflammatory pathology can be
one of the causes. Nevertheless, modular stems and long diaphyseal fit stem
should be kept in case the need arises.5,6,8
Acetabular Reaming
Once the femoral anteversion is set, the acetabular reaming is commenced.
The challenge is to find the true acetabular floor and to not breach it. The
femur is retracted anteriorly with a swan neck retractor so as to visualize
the acetabular area (Fig. 12.7). We use 3 mm Steinmann pins to secure
Fig. 12.7 Posterior exposure to acetabulum. Ant – anterior , Post – posterior, TAL – trans-
verse acetabular ligament.
soft tissues superiorly and posteriorly. This gives us a 360° wide field. The
margins of the true acetabulum can be visualized around the osteotomized
borders of the neck. It is advisable to start with a smaller reamer and start
reaming the osteotomized neck ankylosed with the acetabulum. In most
of the cases, circumferential labral cartilage can be seen after superficial
reaming, reconfirming the correct direction of reaming. Successive ream-
ings would remove trabecular bone of the head until the floor of the
acetabulum is reached. The fat pad in the fossa acetabuli, the unossified
ligamentum teres and the superior border of the obturator foramen can be
good markers to the floor. Care should be taken to do gradual controlled
reaming, so as to preserve as much bone as possible. Intraoperative radio-
graphs are not recommended to confirm the extent of reaming, since they
overestimate or underestimate the extent of the medial acetabular wall.
Alternatively, a 2.5-mm drill bit may be passed through till a give way is
felt. A depth gauge measurement of more than 1 cm is a good assurance to
stop medial reaming. In hips with protrusion, the depth of reaming should
be adjusted according to the preoperative planning. Alternatively, impaction
bone grafting may be utilized if acetabular reaming occurs till the floor of
THE ACETABULUM 0ATIENTS WITH!3 ARE YOUNG AND WOULD REQUIRE MULTIPLE
revisions in their lifetime. They have trabecular continuity between the
head and the acetabulum. We prefer to slightly lateralize the cup so as
to preserve medial acetabular bone stock for further revisions. After the
desired rim fit is obtained, the anterior and inferior osteophytes should be
removed to prevent hinged dislocation.
ACETABULAR CUP PLACEMENT

This step is the most important for ultimate stability of the THA in AS. The
cup needs to be placed in the most appropriate inclination and antever-
sion. Widmer et al. have suggested a cup inclination between 40° and 42°
and combined anteversion of 37°, based on 3D computer modeling in a
THA.7,9,13 Ranawat and others introduced the concept of combined ante-
version of the mated components, normally to be 25°–35° for adult males
and 30°–45° in females for preventing instability.9,14 Subtracting the com-
bined anteversion from the native femoral stem, ante-torsion would give us
the required acetabular anteversion. Alternatively, for the determination of
anatomical acetabular anteversion, the transverse acetabular ligament (TAL)
or the McCollum’s line can be used as a guide. We prefer to use TAL with
the cup being placed parallel to the TAL for anteversion.15 We also use
TAL to evaluate the inclination of
the cup. For a hip without any pelvic
obliquity, the inferior margin of the
acetabular cup should lie just medial
to TAL. As a corollary, in cases of
pelvic obliquity, the cup position
may be adjusted along the plane of
TAL so as to reproduce functional
cup inclination (Fig. 12.8).
It is important to understand the
concept of functional cup antever-
sion. The pelvic tilt has a role to play
Fig. 12.8 Acetabular cup placement and in deciding the functional antever-
relation to transverse acetabular ligament sion of the cup. In a study of normal
(TAL). individuals, the posterior pelvic tilt
(decrease in the sacral slope) was present in 56% of individuals, anterior

pelvic tilt (increase in the sacral slope) in 38%, while only 6% had no pelvic
TILTWHICHMEANSTHEANTERIORFRONTALPLANE!&0 WASPARALLELTOTHECORO-
nal plane of the body in lateral decubitus position.9,16 In majority of the
cases, the sacral slope is reduced and the pelvis is fixed in flexion that does
not change with positioning. Implanting the hip in anatomical anteversion
in such cases would lead to anterior dislocation. Hence, the anteversion
has to be decreased from the original anteversion according to the poste-
rior pelvic tilt by a factor of 0.8 (for every 1° increase in posterior tilt the
anteversion decreases by 0.8°).16,17 The same would hold true for anterior
pelvic tilt, where the anteversion has to be increased by the same factor. For
EXAMPLE&IG SAGITTALVIEWOFTHE,3JUNCTIONSHOWSTHE!&0POS-
Fig. 12.9 Change of anteversion with change in pelvic tilt.

AFP – anterior frontal plane. See explanation in the text.
teriorly tilted (a.k.a. sacral slope decreased/sacrum extended/pelvis flexed/

inferior sacral tip pointing forward) by 15°. If the femoral ante-torsion is
20° and combined anteversion fixed by the surgeon is 45°, then instead of
placing the cup in 25° (45°–20°) of anteversion, the surgeon should place
the cup in 13° [25° – (15° × 0.8)°]. The combined functional version
would be 33° and not 45° with respect to the long axis of the table, which
is the coronal plane then.

After the trial components are put in, the hip should be inspected for
anterior and posterior instability. Cup implantation in posteriorly tilted
pelvis can be a cause of anterior subluxation or frank dislocation. This
requires implantation of an elevated liner in the anterosuperior position.
Table 12.1 gives the guidelines regarding cup positioning.
Table 12.1 Recommendations during acetabular cup placement
Flexion of the sacrum Anteverting the cup to prevent posterior
dislocation
Extension of the sacrum Retroverting the cup to prevent anterior
dislocation
Affected pelvis tilted inferiorly Give more inclination
Affected pelvis tilted superiorly Give less inclination
Bearing Surface Choice

The choice of bearing is a matter of debate. We prefer to use hard-on-hard
ceramic bearing in young patients. However, the bearing choice needs to
be individualized depending on surgeon’s prior experience and current Hip
3OCIETY RECOMMENDATIONS (IGHLY CROSS LINKED POLYETHYLENE (80,% IS
ANEXCELLENTCHOICEOFBEARINGSECONDONLYTOCERAMICBEARINGS@(80,%
elevated liners may be utilized to deal with anterior instabilities in AS.5,18
Closure
The hip is closed in layers under a suction drainage. There is a notable loss
of posterior hip capsule and external rotators are atrophic due to disuse.
Fig. 12.10 Posterior soft tissue closure with quadratus femoris in a fan-shaped fashion.
-OSTOFTHETIMETHEQUADRATUSFEMORISISTHEONLYBULKYMUSCLE0OSTERIOR
soft tissue closure is achieved by translocating the quadratus femoris muscle
sleeve superiorly (Fig. 12.10). Anteriorly, soft tissue is closed by simple
approximation of the cut sleeve between gluteus medius and vastus lateralis.
Additional soft tissue releases may be done like adductor tenotomy and the
PATIENTSHOULDBEKEPTINANABDUCTIONBRACE0OSTOPERATIVE8 RAYSSHOULD
be done to confirm cup and stem positioning and rule out iatrogenic frac-
tures (Fig. 12.11).
Fig. 12.11 Postoperative anteroposterior radiograph show-

ing bilateral uncemented total hip replacement (THR).
Prevention of Heterotrophic Ossification

There is high propensity for development of heterotrophic ossification
(HO) in patients with AS. Risk factors for HO formation are revision sur-
gery and trans-trochanteric surgical approach.
Tips and Pearls for Preventing HO Formation

s !
TLEAST,OFSALINEWASHSHOULDBEGIVENTOREMOVEPUTATIVE(/PRO-
genitor cells in bone reamings and bone debris.
s -USCLEINJURYBYOVERZEALOUSMUSCLERETRACTIONSHOULDBEMINIMIZED
s !LLBONECUTSSHOULDBETAKENWITHSHARPNEWSAWBLADE
s 5NNECESSARYPERIOSTEALSTRIPPINGSHOULDBEAVOIDED
Once set in, the progressive HO formation may hinder the functional
recovery of a patient operated with a THA. Radiotherapy is useful if a
linear dose of 700 cGy is given within 48 h post surgery. The implant
and gonads should be shielded during this procedure. Use of nonsteroidal
anti-inflammatory drugs (NSAIDs) such as indomethacin (75 mg) in three
divided doses for 4–6 weeks has been an easy and controllable prophylaxis
for prevention of HO at our center.9,19
Fractures and Dislocations

Intraoperative fracture is a known possibility. Disuse osteopenia is very
common. The tendon–bone junction is mechanically stronger than the
muscle and the bone. This leads to avulsion fractures of trochanter and spi-
ral oblique fractures of the shaft of femur. Unsafe neck resection may lead
to spiral fractures extending up to the acetabular wall or proximal femur.
Fractures are also possible while positioning the patient. Tips for avoiding
such fractures are as follows.
1. Soft tissue to be released adequately, namely, the psoas major, gluteus
maximus and posterior structures.
2. Rigorous jerking movements should be avoided. Successive increase in
the arc of rotation should be aimed for after progressive releases.
Dislocation rate for primary THA in AS has being less than 0.5% in
our hands. Identification of true acetabulum, intraoperative restoration of
combined anteversion and adequate posterior soft tissue closure are the
crux to achieve these results.
Bilateral vs. Unilateral

Most of the cases would present with varied degrees of bilateral ankylosis.
Majority of the deformities are of abduction and external rotation. Also
there is a fixed coronal pelvic obliquity, which would directly dictate cup
inclination. Unilateral surgery may predispose to higher chances of ipsi-
lateral hip dislocation.20 In bilateral cases, inclination needs to be tweaked
with respect to the coronal plane pelvic obliquity as described before, and
we recommend bilateral simultaneous or bilateral sequential hip replace-
ment in such cases.
Postoperative Rehabilitation
Mobilization of the patient starts with successive increase in the ROM of
the joint to prevent stiffness and formation of HO. Weight bearing may
be started according to patient tolerance. At our center, immediate weight

bearing is started once the drain is out. In the initial few weeks, the patient
is instructed to use the abduction pillow. Due to disuse atrophy of the
lower limb muscles, the patients may take time to gain adequate power.
The recovery is variable and depends on preoperative duration of ankylosis.
Surprisingly, these patients have preserved muscle end plates and their mus-
cles hypertrophy once the range of movement is started. The Harris hip
score should be calculated after 6 months to assess the rehabilitation success.
CONCLUSIONS
1. Taking down a spontaneous ankylosis needs an excellent three-dimen-
sional understanding of the hip anatomy and reconstruction of the joint.
2. Minimal tissue damage and soft tissue handling can decrease the chances
of HO and subsequent result in decrease in functionality.
3. Neck-cut is the most challenging part of the surgical procedure and
needs to be done with caution and safe technique.
4. Use of a single incision dual approach spares the glutei and offers a safe
neck resection.
5. Use of intraoperative anatomical markers like TAL and foveal fat pad
may help in cup placement with regard to anteversion.
6. Alteration in the lumbosacral anatomy should be understood well to
position the cup in the most appropriate functional position.
7. Combined functional anteversion should be restored at the end of the
procedure.
0OSTOPERATIVE REHABILITATION AND PREVENTION OF HETEROTOPIC OSSIFICATION
are crucial for long-term success.
REFERENCES
1. Chopra A, Abdel-Nasser A. Epidemiology of rheumatic musculoskeletal disorders in the
developing world. Best Pract Res Clin Rheumatol 2008;22(4):583–604.
2. Longo D, Fauci A, Kasper D, Hauser S, Jameson J, Loscalzo J. Harrison’s Principles of
Internal MedicineTHED-C'RAW(ILL0ROFESSIONAL
6ANDER#RUYSSEN"-U×OZ 'OMARIZ%&ONT0-ULERO*DE6LAM+"OONEN!ETAL
Hip involvement in ankylosing spondylitis: epidemiology and risk factors associated
with hip replacement surgery. Rheumatology (Oxford) 2010;49(1):73–81.
4. Joshi AB, Markovic L, Hardinge K, Murphy JCM. Total hip arthroplasty in ankylosing
spondylitis: an analysis of 181 hips. J Arthroplasty 2002;17(4):427–33.
"HAN 3 %ACHEMPATI ++ -ALHOTRA 2 0RIMARY CEMENTLESS TOTAL HIP ARTHROPLASTY FOR
bony ankylosis in patients with ankylosing spondylitis. J Arthroplasty 2008;23(6):859–66.
6. van den Berg R, Baraliakos X, Braun J, van der Heijde D. First update of the current
evidence for the management of ankylosing spondylitis with non-pharmacological

treatment and non-biologic drugs: a systematic literature review for the ASAS/EULAR
management recommendations in ankylosing spondylitis. Rheumatology (Oxford)
2012;51(8):1388–96.
7. Nystad TW, Furnes O, Havelin LI, Skredderstuen AK, Lie SA, Fevang B-TS. Hip
replacement surgery in patients with ankylosing spondylitis. Ann Rheum Dis
2014;73(6):1194–97.
7OODWARD,*+AM0#!!NKYLOSINGSPONDYLITISRECENTDEVELOPMENTSANDANAESTHETIC
implications. Anaesthesia 2009;64(5):540–8.
9. Goodman SM, Figgie M. Lower extremity arthroplasty in patients with inflamma-
tory arthritis: preoperative and perioperative management. J Am Acad Orthop Surg
2013;21(6):355–63.
10. Schinsky MF, Nercessian OA, Arons RR, Macaulay W. Comparison of complications
after transtrochanteric and posterolateral approaches for primary total hip arthroplasty.
J Arthroplasty 2003;18(4):430–4.
11. Krismer M. Total hip arthroplasty: A comparison of current approaches. European
Instructional Lectures 2009;9(VI):163-75.
12. Dorr LD, Malik A, Dastane M, Wan Z. Combined anteversion technique for total hip
arthroplasty. Clin Orthop Relat Res 2008;467(1):119–27.
13. Widmer KH, Zurfluh B. Compliant positioning of total hip components for optimal
range of motion. J Orthop Res 2006;22(4):815–21.
14. Ranawat CS, Maynard MJ. Modern technique of cemented total hip arthroplasty. Oper
Tech Orthop 1991;6(3).
*AIN3!DERINTO*"OBAK04HEROLEOFTHETRANSVERSEACETABULARLIGAMENTINTOTALHIP
arthroplasty. Acta Orthop Belg 2013;79(2):135–40.
16. Zhu J, Wan Z, Dorr LD. Quantification of pelvic tilt in total hip arthroplasty. Clin
Orthop Relat Res 2010;468(2):571–5.
17. Moed BR. The modified gibson posterior surgical approach to the acetabulum.
J Orthop Trauma 2010;24(5):315–22.
)DULHAQ - 0ARK +3 $IWANJI 32 9OON 42 7IE *3 4OTAL (IP !RTHROPLASTY FOR
Treatment of Fused Hip With 90° Flexion Deformity. J Arthroplasty. 2010;25(3):498.
e5–498.e9.
19. Chao ST, Joyce MJ, Suh JH. Treatment of heterotopic ossification. Orthopedics
2007;30(6):457–64–quiz465–6.
20. Kim YL, Shin SI, Nam KW,Yoo JJ, Kim Y-M, Kim HJ. Total hip arthroplasty for bilater-
ally ankylosed hips. J Arthroplasty 2007;22(7):1037–41.
CHAPTER 13
Total Hip Arthroplasty in

Protrusio Acetabulae
Javahir A. Pachore, Vikram I. Shah, Amish S. Kshatriya
In acetabular prostrusio, the femoral head migrates medially. The com-

monest causes are due to secondary conditions associated with variety of
inflammatory, metabolic and posttraumatic conditions. Primary or idio-
pathic forms of protrusio were described by OTTO in 1824, which we
commonly refer to as OTTO pelvis.1 This condition is common in females
with bilateral progressive involvement. Thirty-five to forty per cent of pro-
trusio are related to inflammatory arthroplasty. The incidence of protrusio
in rheumatoid arthritis is about 15–20%. The protrusio is also well known
in ankylosing spondylitis. The incidence reported by Dholakia et al. is 7%.2
Our experience of protrusio with rheumatoid arthritis at Bombay hospital
is 53%, which is very high compared to western literature. A total of 150
rheumatoid hips were analyzed, which showed 53% protrusion, and the
maximum were moderate protrusio (unpublished).
The most common method of the radiological measurement of pro-
trusio is Kohler’s line, which is the ilioischial line. Any femoral head or
cup medial to this line by more than 2 mm is considered as protrusio. The
most accurate method for measurement is Gates’s teardrop method.3 The
inter-teardrop line and perpendicular line bisecting teardrop are drawn.
Fig. 13.1 Gates’s teardrop method.

Total Hip Arthroplasty in Protrusio Acetabulae 175
Superior migration is measured from horizontal line, and medial migration

is measured from vertical line. This method gives more accurate estimation
of protrusio because of persistence of teardrop (Fig. 13.1). Even in revision
cases, we are able to see the teardrop identity. Protrusio with pelvic dissocia-
tion can be identified preoperatively on radiographs and CT scan. CT scan
is more valuable for quantifying the bone defect.
Sotelo and Charnley classified protrusio in three varieties.4 The medial
migration of 1–5 mm was called as mild, that of 6–15 mm was called as
moderate and more than 15 mm was called as severe (Fig. 13.2). The medial
A B
C
Fig. 13.2 Grades of protrusion. (A) Mild. (B) Moderate. (C) Severe.
deficiency intraoperatively also has been classified according to the size of

medial defect. This medial defect is always membranous. Type 1 has less
than 1 cm deficiency, type 2 has 1–3 cm deficiency and type 3 has more
than 3 cm deficiency. Type 3 often has a pelvic dissociation.

Normal anatomical position of acetabulum in deformed hip is diffi-
cult. Ranawat et al.5 developed a method to locate the correct anatomical
position of acetabulum and they described isosceles triangle as location of
normal acetabulum position.
Protrusio in joint replacement is a challenge because of abnormal bone.
It is a progressive disease with disturbed remodeling. Progression is usually
gradual. Hasting and Parker reported 2–3 mm/year migration. Ranawat et
al. reported that it is not only 2–3 mm/year medial migration but there is
also superior migration of 4 mm/year. Hasting reported 71% of protrusio
for those who were on corticosteroid therapy or active rheumatoid disease
for those who had progressive protrusion.6
This protrusio which is due to medial and superior migration has an
oblong shape. To make it hemispherical in shape is usually a surgical chal-
lenge. The reaming of this protrusio is an art. The principal of treating
protrusio is to normalize the center of rotation and healing of medial wall
to give good long-term results.
SURGICAL TECHNIQUE
Under anaesthesia, mobility of the hip must be assessed. This gives confi-
dence to the surgeon if there is a good rotation and flexion. Most protrusio
have only a limited flexion range. If rotations are adequate, then neck expo-
sure and dislocation may be easy. Any approach can be considered, but in
general, posterior approach is more preferred. This will allow a trochanteric
osteotomy if needed. In posterior approach, one has to be careful of the
sciatic nerve. Due to protrusio, the sciatic nerve is very close to the trochan-
ter. The dissection of the posterior structures has to be close to the bone.
The mini posterior approach is not recommended in moderate or severe
protrusio. Fair degree of soft tissue release is required, including insertion
of gluteus maximus on the proximal part of femur. Frequently, we need to
release the iliopsoas from the lesser trochanter to get better exposure, which
facilitates the reduction. Mild to moderate protrusio needs capsulotomy
rather than capsular release. Gradual release of soft tissue with internal rota-
tion will facilitate in seeing a part of the neck. Once a part of the neck is
seen, one has to gently flex, adduct and internally rotate to dislocate the hip.
To dislocate the hip, forceful internal rotation should be avoided which can
lead to spiral fracture of femur. Most of these patients have an osteoporotic
femur; hence, one should be careful in dislocating the hip. If one is able to
see the part of the head in some degree of flexion, adduction and internal
rotation, then only should one dislocate the hip. In moderate and severe
protrusio, it is better to do the neck osteotomy in situ after exposing the
part of the neck. Two spikes, placed superiorly and inferiorly to the neck,
give good visualization of neck for osteotomy under vision.
The neck osteotomy should be done carefully, either by using a small
saw blade or doing multiple drills and then using sharp osteotomes to avoid
calcar fracture. After the neck osteotomy, the anterior retractor should be
placed. The placement of anterior retractor for the left hip should be around
10 to 11 O’clock position. For the right hip, it should be around 1 to 2
O’clock position. The reason for putting this retractor at this position is to
avoid neuro-vascular injury; second, this is the thickest part of the acetabu-
lum anteriorly which will avoid fracture. The posterior structures should
be protected with a spike into the ischial tuberosity. The inferior retractor
should be below the transverse acetabular ligament. In protrusion, the trans-
verse acetabular ligament may not be a good anatomical landmark due to
osteophytes. Once we get 360° exposure of the acetabulum, the head can be
extracted. If the head is mobile in the acetabulum, only then is the extrac-
tion possible. The 6.5 mm Schanz pin can be put into the center of head
to facilitate the extraction by rotating manually. If there is fibrous ankylosis
of the femoral head, it is better to ream with a small acetabular reamer.
Gradually, the head can be made thinner and thinner and finally a thin shell
of bone can be scraped. The crucial part of the acetabulum preparation is
to make the acetabulum hemispherical. The mouth of the protrusio is small
and the cavity is large. Gradually, with 1 or 2 mm increments of the mouth
of the acetabulum, it should be made adequately larger, but one has to be
careful in keeping a watch on the anterior and posterior walls (Fig. 13.3).
The direction of acetabular reaming will be according to the anteversion
and the inclination. The reamer should aim around 35°–40° while loading
the socket. After reaming the mouth
with proper degree of anteversion,
trial cup should be used. It is pre-
ferred to ream 1 mm less or same
size, for the trial cup. The peripheral
bone of these cases is usually sclerotic
and does not have expansion capacity.
Mostly, the cup has a peripheral rim
fit. Advance the cup gradually until
Fig. 13.3 Acetabulum reaming. you reach the optimum position;
make sure that you do not excessively lateralize the cup. Once you know the
depth of the trial cup, mark the peripheries on the remaining anterior and
posterior rims. This guides the final placement of acetabulum. Keeping the
trial cup inside, assess the amount of protrusio, which needs to be grafted.
After removing the trial cup, the dome of the acetabulum should be rough-
ened with small reamers so as to open the cancellous bone. Same procedure
should be done to the posterior wall. Try and avoid anterior reaming, as in
most protrusio, the anterior wall is usually very thin. The medial wall should
not be reamed. The fibrous tissue on medial wall should be removed with
a sharp currette but the action should be gentle, as most medial walls are
very thin and papery and there are chances that one may create fractures of
the medial wall. The flexible drill of either 2.7 or 3.2 mm should be used
to do the multiple drilling in a controlled fashion in superior and posterior
segments of the acetabulum. If cancelleous bone has been exposed well, this
multiple drilling may not be required. The bone grafting of the medial wall
must be done with matchstick bone graft from the patient’s own femoral
head (auto graft). The technique of preparation of bone graft from the fem-
oral head is to first take out all the cartilage and hard sclerotic bone from the
femoral head. Make multiple wafery thin slices of 2–3 mm. Then with the
help of a nibbler, cut these bone-like matchsticks. If you are using autograft,
do not wash this graft with saline. Graft should be soaked in the patient’s
own blood. If the autograft is not adequate, allograft can be used from the
bone bank. This allograft is fashioned in the same way as the autograft. Then
these allografts are washed with normal saline multiple times to clean bone
debris fat and soft tissue. After lavaging these grafts, dry them and add the
patient’s own blood from the operating field. The grafts are impacted on the
medial wall of acetabulum in a step wise fashion. Do not add large amounts
of graft at one go. Gradually, the grafts are added and they are impacted
with hemispherical metal punch. The amount of graft will be assessed by
using an acetabulum trial, which is about 2 mm smaller to see the previous
anterior and posterior marks. The grafting is considered adequate with this
trial when the grafts are fully touching the trial cup.
COMPONENT CHOICE
The result of cemented cup in protrusio has not been very satisfactory. Bayley
et al. (1987) reported 50% of loosening in uncemented cups at midterm and
long term. Few centers have reported good results. Rosenberg et al.7 showed
90% survival at 12 years with impaction bone grafting and cemented cup.
If the cemented cup is used, then the dome and posterior wall need
multiple step drilling so as to open the cancellous bone for micro interlock.
Acetabular cementing is technically demanding, which needs experience.
The technique requires hypotensive anaesthesia, multiple anchoring holes,
pulsatile lavage, medial grafting, cement pressurization and use of flanged
socket. Current preference in moderate to severe protrusio has been impac-
tion bone grafting and uncemented cup. Preferably we must use two dome
screws to add extra stability to the construct, which allows medial wall
healing (Fig. 13.4). After implantation, the additional posterior, inferior and
anterior osteophytes must be removed. If these osteophytes are not removed
A B
Fig. 13.4 X-rays of protrusio. (A) Preoperative. (B) Postoperative.
then there are chances of impingement leading to dislocation. Uncemented

cup has encouraging results. Thomas et al. (2001) showed that uncemented
cups in rheumatoid arthritis had a good result at 7.5 years follow up. Their
results included two cases of aseptic loosening and 1 case of ischial osteolysis
due to wear.
Any pelvic dissociation will need acetabular cage for reconstruction.
Two commonly used reconstructs are (1) Bush Sneider cage, which needs
a cemented cup, and (2) Octopus cage, which is uncemented. While using
cemented cup, one precaution that is to be taken is to keep the acetabulum
cup in good anteversion and in a closed fashion. Do not look for the inclina-
tion and version of acetabular cage. The acetabular alignment is independent
of cage placement. This will reduce the rate of dislocation. For uncemented
technology, varieties of acetabular inserts are available such as 10°, 20° and
30° lip liners. The trial liner should be introduced and then reduction is
done. The stability test should be done and depending on that the original
lip liner can be rotated.
The surgical aim in the treatment of protrusio is to bring the normal
center of rotation, build the medial wall and lateralize the cup, which has
been emphasized by Ranawat et al.
We looked into our own series of 150 cases of rheumatoid arthritis
wherein total hip replacement was done. The protrusio hips showed 25.1
mm vertical and 27.2 mm lateral distance from the inter-teardrop line. After
cemented hip replacement, the vertical distance was 22.6 mm and the lateral
distance was 25.8 mm. This indicated that some medialization of the cup had
taken place. Average angle of acetabular inclination was 42°. In uncemented
cup, our vertical distance was 19.75 mm and lateral distance was 30.34 mm.
This indicated that the cups were inferiorized and lateralized with an average
angle of 33° of inclination (Unpublished).
SUMMARY
The key is to identify the bone deficiency on radiographs. The CT scan can
be a great adjuvant tool in preoperative planning. Good exposure is needed.
If there is difficulty in dislocating the hip, then neck osteotomy in situ needs
to be done. Careful reaming with proper version is a key for acetabulum
preparation. Adequate medial grafting is to be considered either by autograft
or allograft. Cemented cups can be only considered in a mild protrusio.
Uncemented cups are preferred for moderate and severe protrusio. For
pelvic dissociation, acetabular cage is the only ideal way of reconstruction.
REFERENCES
1. Otto AW. Seltene Biobachtunge zur Anatomie. Physiologie und Pathogie gehorig, 2nd
ed., Berlin: Andral and Lobsteitiy; 1824.
2. Dholakia KT, Saraf ML, Pachore JA. Total Hip Replacement in Ankylosing Spondylitis.
Book by Richard Coombs. Butterworth; 1989.
3. Gates HS, Poletti SC, Callagahan JJ, et al. Radiographic measurement in protrusio
acetabula. J Arthroplasty 1989;4:347–51.
4. Sotelo-Garza A, Charnley J. The results of Charnley arthroplasty of the hip performed
for protrusio actabuli. Clin Orthop 1978;132:12–18.
5. Ranawat CS, Dorr LD, Inglis AE. Total hip arthroplasty in protrusio of rheumatioid
arthritis. J Bone Joint Surg 1980;62A:1059–65.
6. Hastings DE, Parker SM. Protrusio acetabuli in rheumatioid arthritis. Clin Orthop
1975;108:i.76–83.
7. Bayley J, Christie M, Ewalde et al. Long term results of total hip arthroplasty in protru-
sio acetabuli. J Arthroplasty 1987:2:215–9.
8. Wout W J Rosenberg, B Willem Schreurs, Maaten C De Waal Malefijt, et al. Impacted
morsellized bone grafting and cemented primary total hip arthroplasty for acetabular
protrusion in patients with rheumatoid arthritis: An 8- to 18-year follow-up study of
36 hips. Acta Orthopaedica 2000;71(2):143–6.
PART 3
Total Knee Arthroplasty:

Chapters
16. Tips and Pearls: Tourniquets and Position in Total Knee Arthroplasty 204
17. Tips and Pearls: Exposure and Retractors in Total Knee Arthroplasty 211
18. Tips and Pearls: Saw Techniques in Total Knee Arthroplasty 222
24. Mobile-Bearing Total Knee Arthroplasty: Techinque and Clinical Results 280
26. Total Knee Arthroplasty in the Fixed Flexion Deformity 302
27. Total Knee Arthroplasty in the Stiff Knee 308
PART 3
Total Knee Arthroplasty:

Chapters
16. Tips and Pearls: Tourniquets and Position in Total Knee Arthroplasty 204
17. Tips and Pearls: Exposure and Retractors in Total Knee Arthroplasty 211
18. Tips and Pearls: Saw Techniques in Total Knee Arthroplasty 222
24. Mobile-Bearing Total Knee Arthroplasty: Techinque and Clinical Results 280
26. Total Knee Arthroplasty in the Fixed Flexion Deformity 302
27. Total Knee Arthroplasty in the Stiff Knee 308
Chapter 14
Radiological Planning in Primary

Total Knee Arthroplasty
INTRODUCTION
The aim of total knee replacement is to evenly distribute the load on tibia
by achieving a joint line parallel to the ground. In addition to decreasing
the risk of unforeseen surprises intraoperatively, preoperative planning has
been shown to prolong implant survival1 and reduce duration of surgery.2
Many times, a thorough preoperative planning will prevent unnecessary
additional steps during surgery. For example, identifying preoperatively
the presence of any tenting osteophytes and understanding the soft tissue
sleeve around the knee joint are helpful in obtaining appropriate soft tissue
releases. These measures will elongate the soft tissue sleeve, thus increasing
the gaps, without having to resort to additional bone cuts.
Following information is obtained from preoperative radiographs:
1. Assessment of hip–knee–ankle (HKA) axis to determine the distal val-
gus cut in the absence of computer assisted systems (CAS).
2. Deviations from normal alignment:
a. Evaluation of offset (e.g., post high tibial osteotomy (HTO) cases).
b. Identifying deformity and predicting its correctability; evaluating
need of releases for the deformities.
c. Extra-articular deformities (e.g., posttraumatic, developmental tibia
vara, etc.) to identify site of deformity, and calculate approximate
contribution of that to the joint.
3. Variation in Anatomy: narrow mediolateral width of distal femur in
‘female-type’ knees may warn surgeon to consider deep-dish design
over cam and post, in order to avoid box cut. However, it must be kept
in mind that the width of the distal femur may not be always appreci-
ated well in a plain X-ray (e.g., in a knee with flexion deformity, distal
femur may appear broader due to the oblique projection of X-ray
beams).
4. Bone loss or defects, which may demand augments, cones, metal blocks,
Chapter 14
Radiological Planning in Primary

Total Knee Arthroplasty
INTRODUCTION
The aim of total knee replacement is to evenly distribute the load on tibia
by achieving a joint line parallel to the ground. In addition to decreasing
the risk of unforeseen surprises intraoperatively, preoperative planning has
been shown to prolong implant survival1 and reduce duration of surgery.2
Many times, a thorough preoperative planning will prevent unnecessary
additional steps during surgery. For example, identifying preoperatively
the presence of any tenting osteophytes and understanding the soft tissue
sleeve around the knee joint are helpful in obtaining appropriate soft tissue
releases. These measures will elongate the soft tissue sleeve, thus increasing
the gaps, without having to resort to additional bone cuts.
Following information is obtained from preoperative radiographs:
1. Assessment of hip–knee–ankle (HKA) axis to determine the distal val-
gus cut in the absence of computer assisted systems (CAS).
2. Deviations from normal alignment:
a. Evaluation of offset (e.g., post high tibial osteotomy (HTO) cases).
b. Identifying deformity and predicting its correctability; evaluating
need of releases for the deformities.
c. Extra-articular deformities (e.g., posttraumatic, developmental tibia
vara, etc.) to identify site of deformity, and calculate approximate
contribution of that to the joint.
3. Variation in Anatomy: narrow mediolateral width of distal femur in
‘female-type’ knees may warn surgeon to consider deep-dish design
over cam and post, in order to avoid box cut. However, it must be kept
in mind that the width of the distal femur may not be always appreci-
ated well in a plain X-ray (e.g., in a knee with flexion deformity, distal
femur may appear broader due to the oblique projection of X-ray
beams).
4. Bone loss or defects, which may demand augments, cones, metal blocks,
184 Part 3 | Total Knee Arthroplasty: Techniques and Pearls
extenders, etc., depending upon the defect size. Extra inventory may
have to be kept ready on the table in these scenarios.
5. Evaluation for the need of special exposures, e.g., Patella Baja requiring
quadriceps snip or tibial tubercle osteotomy.
6. Reasonably accurate prediction of component size. Although the accu-
racy of prediction of femoral and tibial component size prediction is
only 60–65% for the exact same size, it increases to 90–95% when one
size smaller and larger is considered in to calculations. As mentioned
previously, due to oblique projection of X-ray beams, templating in
an anteroposterior (AP) X-ray may not be accurate. However, a lateral
X-ray with overlapping condylar shadows may give the rough estimate
of the size with templating. As far as digital vs. analog templating is
concerned, the differences are equivocal.
7. Variation in femoral neck shaft angle, femoral bowing, or previously
performed total hip arthroplasty may affect the distal valgus cut, hence
hip and proximal femur must be screened radiographically while doing
planning for total knee arthroplasty (TKA).
HOW TO PLAN
Good radiological planning requires an anteroposterior, lateral and patel-
lar (merchant/sunrise, etc.) views of knee, plus a long leg alignment film
(from hip to ankle) (Fig. 14.1). Radiographs should be obtained in weight-
bearing position.
Planning ideally should be done by visualizing the center of femoral
head and then drawing the mechanical axis from that point. In cases where
femoral head could not be visualized due to small size X-rays, tall patient,
or technical difficulties, the anatomical axis of femur is drawn instead.
The mechanical axis of femur can be derived from the anatomical axis
by adding 6°. Things are simpler on tibial side, with both anatomical and
mechanical axis coinciding. And what is more, the axes bisect the proximal
tibial metaphysis. Thus, when you do not have a long leg film till ankle,
you can still find the axes by joining midpoint of proximal tibial metaphy-
sis with midpoint of the knee.
After drawing the axes on femur and tibia, the cuts are drawn on the
X-ray. The normal anatomical tibia has a 3° varus surface, with a 9° valgus
on femur, resulting in a 6° effective valgus at the knee joint. But while
doing TKA, the tibial cut is taken perpendicular to the mechanical axis,
extenders, etc., depending upon the defect size. Extra inventory may
have to be kept ready on the table in these scenarios.
5. Evaluation for the need of special exposures, e.g., Patella Baja requiring
quadriceps snip or tibial tubercle osteotomy.
6. Reasonably accurate prediction of component size. Although the accu-
racy of prediction of femoral and tibial component size prediction is
only 60–65% for the exact same size, it increases to 90–95% when one
size smaller and larger is considered in to calculations. As mentioned
previously, due to oblique projection of X-ray beams, templating in
an anteroposterior (AP) X-ray may not be accurate. However, a lateral
X-ray with overlapping condylar shadows may give the rough estimate
of the size with templating. As far as digital vs. analog templating is
concerned, the differences are equivocal.
7. Variation in femoral neck shaft angle, femoral bowing, or previously
performed total hip arthroplasty may affect the distal valgus cut, hence
hip and proximal femur must be screened radiographically while doing
planning for total knee arthroplasty (TKA).
HOW TO PLAN
Good radiological planning requires an anteroposterior, lateral and patel-
lar (merchant/sunrise, etc.) views of knee, plus a long leg alignment film
(from hip to ankle) (Fig. 14.1). Radiographs should be obtained in weight-
bearing position.
Planning ideally should be done by visualizing the center of femoral
head and then drawing the mechanical axis from that point. In cases where
femoral head could not be visualized due to small size X-rays, tall patient,
or technical difficulties, the anatomical axis of femur is drawn instead.
The mechanical axis of femur can be derived from the anatomical axis
by adding 6°. Things are simpler on tibial side, with both anatomical and
mechanical axis coinciding. And what is more, the axes bisect the proximal
tibial metaphysis. Thus, when you do not have a long leg film till ankle,
you can still find the axes by joining midpoint of proximal tibial metaphy-
sis with midpoint of the knee.
After drawing the axes on femur and tibia, the cuts are drawn on the
X-ray. The normal anatomical tibia has a 3° varus surface, with a 9° valgus
on femur, resulting in a 6° effective valgus at the knee joint. But while
doing TKA, the tibial cut is taken perpendicular to the mechanical axis,
Radiological Planning in Primary Total Knee Arthroplasty 185
and in turn, the distal femoral valgus

cut is taken at 6°. To prevent the
flexion gap asymmetry, femoral cut
is taken at 3° external rotation.
The 6° femoral valgus is derived
from the angle between the anatom-
ical and mechanical axes of femur,
and ideally, one should find the
angle in every patient and reproduce
it, instead of taking a 6° standard cut
in all patients.
The next step is identifying
deformities, their correctability and
possible methods to counter the
deformity without additional bone
cuts. For example, large tenting
osteophytes should be identified and
marked on the X-ray. Before doing
any soft tissue releases or additional
cuts during surgery, these tenting
osteophytes should be removed by
surgeon to reassess how much cor-
rection could be achieved. Extra-
articular deformities are discussed in
the next section.
The next step is to look for spe-
cial situations like bone loss. This
will help to anticipate additional
inventories like augments, cones,
extenders, etc. Also certain extreme
Fig. 14.1 Planning for total knee arthro- bone loss scenarios will demand
plasty (TKA) on a scannogram film with specific designs like hinged knee.
mechanical and anatomical axes drawn.
Dynamic radiographs are very help-
ful in this scenario to evaluate correctability after a bone loss. Also, a large
tibial defect should warn the surgeon to undercut the tibia.
The final step is templating. Transparent templates are available for
superimposition. These must always be compared with manual X-rays of
appropriate magnification to give surgeon some idea about the compo-
nent sizes. Also, in cases of high tibial osteotomy, the need for an offset
and in turn, the distal femoral valgus

cut is taken at 6°. To prevent the
flexion gap asymmetry, femoral cut
is taken at 3° external rotation.
The 6° femoral valgus is derived
from the angle between the anatom-
ical and mechanical axes of femur,
and ideally, one should find the
angle in every patient and reproduce
it, instead of taking a 6° standard cut
in all patients.
The next step is identifying
deformities, their correctability and
possible methods to counter the
deformity without additional bone
cuts. For example, large tenting
osteophytes should be identified and
marked on the X-ray. Before doing
any soft tissue releases or additional
cuts during surgery, these tenting
osteophytes should be removed by
surgeon to reassess how much cor-
rection could be achieved. Extra-
articular deformities are discussed in
the next section.
The next step is to look for spe-
cial situations like bone loss. This
will help to anticipate additional
inventories like augments, cones,
extenders, etc. Also certain extreme
Fig. 14.1 Planning for total knee arthro- bone loss scenarios will demand
plasty (TKA) on a scannogram film with specific designs like hinged knee.
mechanical and anatomical axes drawn.
Dynamic radiographs are very help-
ful in this scenario to evaluate correctability after a bone loss. Also, a large
tibial defect should warn the surgeon to undercut the tibia.
The final step is templating. Transparent templates are available for
superimposition. These must always be compared with manual X-rays of
appropriate magnification to give surgeon some idea about the compo-
nent sizes. Also, in cases of high tibial osteotomy, the need for an offset
stem will be apparent during tem-

plating (see Fig. 14.2). Digital tem-
plating softwares are now available
in some places and their popularity
will increase in coming years.
EXTRAARTICULAR
DEFORMITIES
Extra-articular deformities can occur
due to trauma or developmental dis-
orders. The distance of the site of
deformity determines how much
it contributes to the deviation at
the joint. For example, a 10° varus
deformity in tibia which is at the
junction of proximal one-fourth and
distal three-fourths of tibia will con-
Fig. 14.2 Templating of tibia in a post high
tibial osteotomy (HTO) scenario showing
tribute 7.5° varus at knee joint. In
need for an offset stem. other words, the influence of extra-
articular deformity is inversely pro-
portional to the distance from knee – the farther it is, the less influential it
becomes. By calculating this contribution, the correction of deformity can
be planned. For further details, the reader is referred to the monograph by
Krackow and Rauh.3
While correcting deformities, the osteotomy can be done at the apex
of the deformity (CORA). Instead, the deformity can also be corrected
nearer to the articular surface after first calculating the contribution of the
extra-articular deformity to the deviation at the knee joint.
CT vs. XRAY
The advantage of CT over X-ray for preoperative planning involves (a)
the ability to measure angles and distances in three dimensions, and (b)
greater accuracy. In addition, the problems associated with plain X-ray
(e.g., perspective distortion, magnification errors, orientation uncertainties)
are overcome with CT scan. However, concern has been raised because of
the amount of radiation dose. The traditional long leg radiograph leads to
stem will be apparent during tem-

plating (see Fig. 14.2). Digital tem-
plating softwares are now available
in some places and their popularity
will increase in coming years.
EXTRAARTICULAR
DEFORMITIES
Extra-articular deformities can occur
due to trauma or developmental dis-
orders. The distance of the site of
deformity determines how much
it contributes to the deviation at
the joint. For example, a 10° varus
deformity in tibia which is at the
junction of proximal one-fourth and
distal three-fourths of tibia will con-
Fig. 14.2 Templating of tibia in a post high
tibial osteotomy (HTO) scenario showing
tribute 7.5° varus at knee joint. In
need for an offset stem. other words, the influence of extra-
articular deformity is inversely pro-
portional to the distance from knee – the farther it is, the less influential it
becomes. By calculating this contribution, the correction of deformity can
be planned. For further details, the reader is referred to the monograph by
Krackow and Rauh.3
While correcting deformities, the osteotomy can be done at the apex
of the deformity (CORA). Instead, the deformity can also be corrected
nearer to the articular surface after first calculating the contribution of the
extra-articular deformity to the deviation at the knee joint.
CT vs. XRAY
The advantage of CT over X-ray for preoperative planning involves (a)
the ability to measure angles and distances in three dimensions, and (b)
greater accuracy. In addition, the problems associated with plain X-ray
(e.g., perspective distortion, magnification errors, orientation uncertainties)
are overcome with CT scan. However, concern has been raised because of
the amount of radiation dose. The traditional long leg radiograph leads to
absorbed dose of 0.7 mSv, whereas the lower limb CT Perth protocol leads
to absorption of 2.7 mSv. The recently developed Imperial Knee Protocol
(Henckel et al.)4 further defined an algorithm to reduce the amount of
absorbed dose to 0.7 mSv in females and 0.5 mSv in males. Decreased
radiation dose, shorter scanning time and cheaper cost of scanning will be
the factors that will drive more adoption of CT for planning and outcome
measurement in TKA.
ROLE OF MRI
Compared to CT scannogram, which had a place in TKA planning since a
long time, MRI has not been traditionally used for preoperative planning.
However, things are changing with patient-specific instrumentation (PSI).
CT scans or MRIs are utilized for manufacturing patient-specific instru-
mentation, and in some cases, patient-specific implants too. Not all patients
are suitable for MRI-based planning (e.g., patients with pacemakers). The
cost and scanning time are also on the higher side. With the advent of
patient-specific surgeries, the role of MRI is poised to grow.
ANALOG vs. DIGITAL TEMPLATING

Preoperative planning has traditionally been done on analog true size films.
The facilities of digital templating may not be as widely available every-
where, particularly in developing countries. Nonetheless, the other benefits
of digital imaging (i.e., easier to store and archive, view across multiple ter-
minals, etc.) are going to drive the adoption of digital templating in future.
As far as the accuracy between digital and analog templating is concerned,
the difference is equivocal.5
SPECIAL RADIOGRAPHIC VIEWS BEFORE

UNICOMPARTMENTAL KNEE ARTHROPLASTY
In addition to standard radiographs, preoperative stress X-rays are essential
before a unicompartmental knee arthroplasty. The X-rays are taken with
patient being supine, with knee in 20° flexion. The X-ray beam is angled
10° cranially. This ensures that the X-ray beams are parallel to the tibial
joint surface (Fig. 14.3). It must be ensured that the knee remains in neu-
tral rotation with patella at the center, facing forward. Valgus and varus
absorbed dose of 0.7 mSv, whereas the lower limb CT Perth protocol leads
to absorption of 2.7 mSv. The recently developed Imperial Knee Protocol
(Henckel et al.)4 further defined an algorithm to reduce the amount of
absorbed dose to 0.7 mSv in females and 0.5 mSv in males. Decreased
radiation dose, shorter scanning time and cheaper cost of scanning will be
the factors that will drive more adoption of CT for planning and outcome
measurement in TKA.
ROLE OF MRI
Compared to CT scannogram, which had a place in TKA planning since a
long time, MRI has not been traditionally used for preoperative planning.
However, things are changing with patient-specific instrumentation (PSI).
CT scans or MRIs are utilized for manufacturing patient-specific instru-
mentation, and in some cases, patient-specific implants too. Not all patients
are suitable for MRI-based planning (e.g., patients with pacemakers). The
cost and scanning time are also on the higher side. With the advent of
patient-specific surgeries, the role of MRI is poised to grow.
ANALOG vs. DIGITAL TEMPLATING

Preoperative planning has traditionally been done on analog true size films.
The facilities of digital templating may not be as widely available every-
where, particularly in developing countries. Nonetheless, the other benefits
of digital imaging (i.e., easier to store and archive, view across multiple ter-
minals, etc.) are going to drive the adoption of digital templating in future.
As far as the accuracy between digital and analog templating is concerned,
the difference is equivocal.5
SPECIAL RADIOGRAPHIC VIEWS BEFORE

UNICOMPARTMENTAL KNEE ARTHROPLASTY
In addition to standard radiographs, preoperative stress X-rays are essential
before a unicompartmental knee arthroplasty. The X-rays are taken with
patient being supine, with knee in 20° flexion. The X-ray beam is angled
10° cranially. This ensures that the X-ray beams are parallel to the tibial
joint surface (Fig. 14.3). It must be ensured that the knee remains in neu-
tral rotation with patella at the center, facing forward. Valgus and varus
Fig. 14.3 Position for imaging for ensuring that X-ray beams
are parallel to tibial joint surface.
Fig. 14.4 Valgus stress view before a uni- Fig. 14.5 Varus stress view before a uni-
compartmental knee arthroplasty. compartmental knee arthroplasty.
stress views are obtained (Figs 14.4 and 14.5). The valgus stress view gives
information about the correctability of the deformity and the involvement
of lateral compartment. The varus stress view should reveal bone on bone
disease. In valgus view, varus should be correctible in 20° of flexion and
lateral joint space should not close completely. This suggests that lateral
compartment cartilage is relatively intact and no release is needed to cor-
rect the varus deformity. If the varus is not correctible in valgus stress X-ray
Fig. 14.3 Position for imaging for ensuring that X-ray beams
are parallel to tibial joint surface.
Fig. 14.4 Valgus stress view before a uni- Fig. 14.5 Varus stress view before a uni-
compartmental knee arthroplasty. compartmental knee arthroplasty.
stress views are obtained (Figs 14.4 and 14.5). The valgus stress view gives
information about the correctability of the deformity and the involvement
of lateral compartment. The varus stress view should reveal bone on bone
disease. In valgus view, varus should be correctible in 20° of flexion and
lateral joint space should not close completely. This suggests that lateral
compartment cartilage is relatively intact and no release is needed to cor-
rect the varus deformity. If the varus is not correctible in valgus stress X-ray
in 20° of flexion or lateral joint space closes completely, then the case is
unsuitable for unicompartmental knee arthroplasty.
PLANNING FOR PATIENTSPECIFIC INSTRUMENTS

AND IMPLANTS
Patient-specific instrumentation and implants shift the time and effort of
computer navigation from inside the OT to preoperative period. The pro-
cess involves submission of preoperative CT/MRI by the surgeon to the
manufacturer, usually using a specific protocol. The manufacturer analyzes
the data with the help of specialized computer programs and creates a sur-
gical plan for the approval of the surgeon. The manufacturer then fabricates
single-use instruments (cutting jigs/ custom cutting blocks) for femoral and
tibial resections specific to that patient (e.g.,Visionaire System of Smith and
Nephew, Signature System of Biomet).
REFERENCES
1. Schwartz JT, Mayer JG, Engh CA. Femoral fracture during non-cemented total hip
arthroplasty. J Bone Joint Surg 1989;71-A:1135.
2. Blackley HR, Howell GE, Rorabeck CH. Planning and management of the difficult
primary hip replacement: preoperative planning and technical considerations. Instr
Course Lect 2000;49:3.
3. Krackow K, Rauh MA. The Measurement and Analysis of Axial Deformity at the Knee.
Buffalo, NY: Kaleida Health System, 2001.
4. Henckel J, Richards R, Lozhkin K, Harris S, Rodriguez y Baena FM, Barrett AR, Cobb
JP. Very low-dose computed tomography for planning and outcome measurement in
knee replacement. The imperial knee protocol. J Bone Joint Surg Br 2006;88(11):1513–
18. PubMed PMID: 17075100.
5. Miller AG, Purtill JJ. Total knee arthroplasty component templating: a predictive model.
J Arthroplasty 2012;27(9):1707–09. doi:10.1016/j.arth.2012.03.055. Epub 2012 May 23.
Chapter 15
Selection of the Implant in Total

Knee Arthroplasty
H.P. Bhalodiya, Somesh P. Singh
There has been no consensus regarding the preferable features in a knee

prosthesis over several past decades in spite of multiple design philoso-
phies being available to the surgeons. Also there has been continuous
debate regarding which philosophy is better while choosing, namely,
a cruciate retaining (CR) implant or posterior stabilizing implant or
selection based on case to case. Whether to choose a fixed-bearing
implant or a rotating platform implant? Whether to choose a cemented
fixation or an uncemented fixation. One of the reasons for continuous
debate may be because of the multiple variables involved in the evalua-
tion of knee prosthesis, making it difficult to compare with each other
in terms of proving superiority of one over the other. The implants we
use now are different in important ways from those reported in most
long-term follow-up studies. These longer-term studies also reflect a
significantly different patient population than that currently presenting
for knee replacement.1 Also surgeons must be aware that data reflected
in the literature is from a completely different set of population and
different design philosophy than what one is facing during the day-to-
day practice. The patients are more younger, more active and with high
demand on knee joint.
There has been a systematic improvement in quality and consistency
of performance of total knee replacement surgery due to continuous
improvement in design philosophies, better material availability, better
surgical technique and improvement of postoperative care. These advances
have given surgeons the confidence to offer knee replacements to younger
and less severely affected individuals who were not previously considered
sufficiently debilitated or aged to undergo total knee arthroplasty (TKA).
In addition, we are getting better at mobilizing our patients by reducing
postoperative pain.2
Selection of the Implant in Total Knee Arthroplasty 191
POSTERIOR CRUCIATE RETAINING TOTAL KNEE

REPLACEMENT FIG. 15.1
In the early 1980s, CR knees domi-
nated the market; approximately
85% of knees that were implanted
were of this design. The devel-
opment of universal instruments
allowed surgeons outside of special-
ized joint centers to implant these
knees. This knee design provided
patients with better motion com-
pared to the early total condylar
knee. However, there were prob-
lems with the early CR designs of
this era. This was a period when
problems with polyethylene manu-
facturing had yet to be recognized.
The polyethylene in this implant
Fig. 15.1 Posterior cruciate retaining knee. was thin with a flat-on-flat design.
Metal-backed patellae were also commonly used in this era. Not surpris-
ingly, these characteristics led to early osteolysis, loosening and polyeth-
ylene failure. With more CR knees being implanted than posterior stabi-
lized (PS) during this time period, the relative number of CR knees that
failed was much higher than the PS knees. Consequentially, the PS knee
began to increase in surgeon preference. In the meantime, design changes
addressing the issues that led to early failure of the early CR implants
were made. The implants we now use today are direct descendants of the
original duocondylar and total condylar knee systems. Both the PS and
CR knees have been modified to provide improved flexion and longev-
ity of the implants. Today, most of the differences between the two knee
designs are of historical interest. Long-term follow-up has shown no dif-
ference in survivorship of the two designs.
Supporters of posterior cruciate ligament (PCL) retaining design
showcase the concept of simply resurfacing the joint that sounds an
appealing one. The bone loss is less, the loads are transferred to a cen-
tral ligamentous structure rather than a mechanical one, natural femoral
rollback is recreated and joint line is maintained, specific PS knee com-
plications like patellar clunk syndrome and post wear are avoided and
there is better proprioception from the joint and stair climbing ability.
Recent reports have shown it to be equally effective in correction of
large deformities and even in inflammatory arthritis such as rheumatoid
arthritis. However, proper surgical technique and balancing of PCL
are essential prerequisite as is protection of PCL from intraoperative
inadvertent damage. Rasquinha et al.3 has published 12-year follow-
up data on 150 consecutive PS knees with a 94.6% survivorship. This
compares to Dixon et al.,4 who reported 92.6% 15-year survivorship
on 139 CR knees, as well as Rodricks et al.,5 who reported 92.9%
overall survival in a report of a 17-year follow-up on 160 CR knees.4,5
Outcomes are similar between implant designs even when the surgery
is performed at nonacademic institutions and in younger patients. Gioe
et al.6 reviewed outcomes of 1047 patients aged 55 and younger in a
community registry database, there was no difference in revision rates
between the PS and CR knees. They report an overall 84.5% 14-year
survival for cemented total knee replacement in this relatively young
patient population.6 Multiple comparative studies have shown no differ-
ence in functional outcome scores between the two implant designs.7–9
However, there is still some debate as to whether there are real differ-
ences in range of motion between CR and PS knees. A meta-analysis
in 2005 of eight well-designed randomized studies found a statistically
significant 8° increase in range of motion (ROM) for PS knees with a
cam and postdesign.10 This finding has not been universally true in all
studies. For example, Tanzer et al.11 compared 40 knees of PS and CR
design and found no statistical difference in ROM, with average motion of
112° ± 13° for the CR and 111° ± 17° for the PS. In contrast, Maruyama
et al.12 reviewed 20 bilateral knees and found an average ROM in CR
knees of 112° ± 15° compared with 131° ± 13° in PS knees, a statistically
significant difference. However, with such a wide range of measured
motion in both designs, the clinical significance that an average 8° dif-
ference in flexion has is debatable, as both designs allow for more than
105°, which is what is needed to successfully climb stairs and arise from a
seated position.13,14 To study the effect on proprioception with retention
or substitution of PCL, Swanik et al.15 compared proprioception and
balance before and after TKA randomized to a PS or CR knee. Although
both proprioception and balance improved following knee replacement,
there was no significant difference between the two implant designs.
POSTERIOR STABILIZING TOTAL KNEE REPLACEMENT

FIG. 15.2
Indications of PS knee:
1. Severe deformities (more than 20°)
2. Inflammatory arthritis
3. Postpatellectomy
4. Altered geometry of femur and/or tibia (previous osteotomy)
5. PCL-deficient knee
Contraindication: Contraindication is when one or both of the col-
lateral ligaments are significantly lax or disrupted. Failure to obtain bal-
anced extension and flexion gaps after PCL resection necessitates conver-
sion to a varus–valgus constrained implant.
A posterior CR design TKA pro-
vides minimal constraint and relies on
an intact, well-balanced PCL to create
proper femoral rollback. Proponents of
a CR design cite potential advantages
such as more normal knee kinemat-
ics, increased quadriceps strength due
to the increased moment arm of the
extensor mechanism, improved stair-
climbing ability, preserved proprio-
ception, decreased patellar complica-
Fig. 15.2 Posterior stabilizing knee. tions, diminished shear forces at the
tibial component bone interface and maintenance of distal femoral bone
stock.1,2,16,17 However, all these claims are predicated on an intact and
properly tensioned PCL. A posterior cruciate substituting a PS design
removes the PCL and relies on a more conforming articular surface, as well
as a polyethylene tibial post and femoral cam to provide restraint against
posterior translation of the tibia and proper femoral rollback. Potential
advantages of a PS design include more predictable restoration of knee
kinematics, improved ROM, decreased polyethylene wear because of
more congruent articular surfaces, easier correction of severe deformities
and easier ligament balancing.1 While eliminating the reliance on a well-
functioning PCL, a PS design introduces the risk of component dislocation
with flexion instability, tibial post and femoral cam impingement, creating
polyethylene wear, patellofemoral problems and increased bone resection
of the distal femur.16,18
POSTERIOR STABILIZING TOTAL KNEE REPLACEMENT

FIG. 15.2
Indications of PS knee:
1. Severe deformities (more than 20°)
2. Inflammatory arthritis
3. Postpatellectomy
4. Altered geometry of femur and/or tibia (previous osteotomy)
5. PCL-deficient knee
Contraindication: Contraindication is when one or both of the col-
lateral ligaments are significantly lax or disrupted. Failure to obtain bal-
anced extension and flexion gaps after PCL resection necessitates conver-
sion to a varus–valgus constrained implant.
A posterior CR design TKA pro-
vides minimal constraint and relies on
an intact, well-balanced PCL to create
proper femoral rollback. Proponents of
a CR design cite potential advantages
such as more normal knee kinemat-
ics, increased quadriceps strength due
to the increased moment arm of the
extensor mechanism, improved stair-
climbing ability, preserved proprio-
ception, decreased patellar complica-
Fig. 15.2 Posterior stabilizing knee. tions, diminished shear forces at the
tibial component bone interface and maintenance of distal femoral bone
stock.1,2,16,17 However, all these claims are predicated on an intact and
properly tensioned PCL. A posterior cruciate substituting a PS design
removes the PCL and relies on a more conforming articular surface, as well
as a polyethylene tibial post and femoral cam to provide restraint against
posterior translation of the tibia and proper femoral rollback. Potential
advantages of a PS design include more predictable restoration of knee
kinematics, improved ROM, decreased polyethylene wear because of
more congruent articular surfaces, easier correction of severe deformities
and easier ligament balancing.1 While eliminating the reliance on a well-
functioning PCL, a PS design introduces the risk of component dislocation
with flexion instability, tibial post and femoral cam impingement, creating
polyethylene wear, patellofemoral problems and increased bone resection
of the distal femur.16,18
Correction of preoperative deformities is possible with both a CR and

PS total knee. While a CR design mandates optimal balance of the PCL, a
PS design offers possible easier correction of coronal deformities, especially
when combined with a flexion contracture.19,20 A flexion contracture often
requires a larger distal femoral resection so as to restore the extension space.
Although both CR and PS knees require creation of symmetric extension
and flexion gaps, the joint line must be restored in a CR knee to properly
balance the PCL.21 Since a larger distal femoral resection will raise the joint
line, a CR knee relies on an increased tibial resection to address a flexion
contracture. This increased tibial resection may place the tibial component
on weaker metaphyseal bone.21 Av PS knee provides more freedom to raise
the joint line, which aids in the correction of a flexion contracture. However,
improper gap balancing places the PS knee at risk for dislocation. The PCL
often contributes to severe deformities, and its function can be significantly
diminished if it requires an extensive release for balancing.19 An extensive
PCL release also introduces the risk of late instability or rupture.21 Removal
of the PCL creates at least a 1.0–1.3 mm increase in both extension and flex-
ion gaps.22 Therefore, PCL resection offers the advantage of more straight-
forward gap balancing, improved access to the posterior aspect of the knee
and improved exposure to the proximal tibia while avoiding the need for
subjective release of the PCL, especially with severe deformities.19–21
MOBILEBEARING OR FIXEDBEARING FIG. 15.3

In 1998, John Insall stated, ‘The kine-
matic conflict between low stress
articulations and free rotation can-
not be solved by any fixed bearing
design. …Fixed-bearing knee designs
have reached their ultimate expression;
often, this stage of development indi-
cates impending obsolescence.’ Mobile-
bearing knees offer an attractive avenue
for future development.23 Mobile-
bearing knee replacement systems were
designed to prevent mechanical loosen-
ing and wear, the two primary short-
comings of early knee replacement
Fig. 15.3 Mobile-bearing knee. systems. Doug Noiles, an engineer with
US Surgical Corporation, was one of the pioneers in recognizing that a dual

articulation rotating-platform prosthesis would resolve the kinematic conflict
between low stress articulation and high bearing conformity. He postulated
that the high stresses at the tibial bone interface in conforming fixed-bearing
implants would be significantly reduced by allowing rotation through the
polyethylene tibial base plate interface. Forces generated during normal
ambulation were ‘not transmitted to the prosthesis bone interface.’ This also
allowed greater conformity between the femoral component and polyethyl-
ene, increasing contact areas and minimizing contact stresses.
In 1976, Noiles obtained a patent for the PS rotating platform knee and
revision system. Richard ‘Dickey’ Jones performed many of the early clini-
cal trials on the system and helped develop the P-ROM, a press-fit condylar
(PFC) femoral component, and a primary S-ROM tibial component with
a mobile-bearing. With extensive European experience and clinical trials,
the Noiles PS rotating platform knee eventually evolved into the PFC
Sigma rotating-platform prosthesis (DePuy Orthopaedics Inc.).
Following their design of the ‘floating-socket’ total shoulder, Fred
Buechel, an orthopaedic surgeon, and engineer Michael Pappas were con-
vinced that the mobile-bearing concept could resolve the dilemma.
Between congruency and constraint in TKA designs,24–26 the New
Jersey Integrated Knee Replacement System was developed with a large
radius of curvature in extension that was symmetrical in the sagittal and
coronal planes and a narrower radius in the posterior condyle. This design
maximized contact areas in extension where loading is highest and allowed
for improved flexion.
In the early 1980s, DePuy Orthopaedics developed the low contact
stress (LCS) knee from the New Jersey Knee System. The LCS knee
again maximized conformity with a matching coronal and sagittal radius
of the femoral component and the radii of the tibial polyethylene. There
was also high conformity between the patella and the anterior flange of
the component. This all contributes to very LCSs, potentially minimizing
polyethylene wear. The evolution of the LCS implant eventually offered a
variety of surgical options. Meniscal bearings allowed the surgeon to retain
the cruciate ligaments, and the rotating-platform option allowed sacrificing
the cruciate ligaments whenever appropriate.
Indications and Contraindications

Patients with disabling knee pain unresponsive to conservative measures are
good candidates to receive a mobile-bearing TKA. Patient selection is guided
by patient expectations. Patients implanted with a mobile-bearing TKA

may benefit from potential increase in ROM over fixed-bearing conven-
tional knee systems, especially with higher flexion requirements.27 Since the
patients are younger, heavier and more active, along with having increased life
expectancy, there is a need for increased TKA implant survivorship, functional
performance and load tolerance. Patients with significant coronal deformity,
20° of valgus, and 25–30° of varus may not have the adequate remaining soft
tissues needed to create well-balanced flexion and extension gaps necessary
to prevent instability and possible spinout. A more constrained polyethylene
should be available for these cases as well as a fixed-bearing component.
Advantages of Mobile-Bearing
Mobile-bearing total knee replacement offers two distinct advantages over
fixed-bearing total knee replacement prosthesis. First is that it has better wear
characteristics with higher surface contact area as compared to fixed-bearing
with flat-on-flat design.This has been proven by multiple large retrieval stud-
ies. Second is that it avoids the possibility of malalignment of tibial compo-
nent in terms of appropriate rotation of the component. The knee has the
normal function of tibial internal rotation that occurs with flexion of the
joint. Diseased state of the joint along with anatomical variations gives very
few reliable landmarks to attain proper rotation of the tibial component in
a fixed-bearing TKA. On the other hand, in mobile-bearing, the insert can
attain proper rotation independent of tibial base plate position.
Results of Mobile-Bearing
No published outcome study has demonstrated superior results of mobile-
bearing TKA over fixed-bearing TKA.28,29 Callaghan30 has stated, however,
that the results of mobile-bearing TKA should be at least equivalent to the
results of fixed-bearing TKA. Callaghan et al.31 reported 97% survival of the
low contact stress mobile-bearing knee at 15 years. Sorrells et al.32 reported
88% survival at 13 years in younger patients, under the age of 65, using the
same system. Long-term studies of the low contact stress mobile-bearing
knee system by Beuchel et al.33,18 reported 98% survival at 20 years. None
of these studies found more than 1% periarticular osteolysis at medium-
and long-term follow-up, validating the concept of minimal surface wear
with mobile-bearing TKA. The scientific basis of mobile-bearing TKA is
now firmly established. Wear testing data and dynamic kinematic motion
studies highlight potential advantages of mobile-bearing TKA. These
include decreased contact stresses and wear on the polyethylene inserts and
reduced stresses transmitted to the implant–bone interface. Further clinical
studies are ongoing.
ALL POLY OR METAL BACK TIBIAL COMPONENTS

FIG. 15.4
Metal back designs are traditionally considered gold standard and time
tested for all types of total knee replacements. Advantages include options
for insert modularity, stem extension and wedges, cementless fixation and
possibility of insert change in setting of infection or late isolated liner
wear out.
Fig. 15.4 All poly or metal backed tibia.
However, the issues of backside wear and increased osteolysis have

been observed. In modern era, all poly tibia components have been shown
to be equivalent and even superior in some aspects vis-à-vis metal back
component. Advantages include increased polythelene thickness, avoidance
of locking mechanisms issues and backside wear, less osteolysis and lower
cost. Disadvantages include limitations in term of options of wedges, stem
extensions and cementless fixation, no possibility for liner exchange in cases
of infection and instability and relatively difficult surgical technique.
include decreased contact stresses and wear on the polyethylene inserts and
reduced stresses transmitted to the implant–bone interface. Further clinical
studies are ongoing.
ALL POLY OR METAL BACK TIBIAL COMPONENTS

FIG. 15.4
Metal back designs are traditionally considered gold standard and time
tested for all types of total knee replacements. Advantages include options
for insert modularity, stem extension and wedges, cementless fixation and
possibility of insert change in setting of infection or late isolated liner
wear out.
Fig. 15.4 All poly or metal backed tibia.
However, the issues of backside wear and increased osteolysis have

been observed. In modern era, all poly tibia components have been shown
to be equivalent and even superior in some aspects vis-à-vis metal back
component. Advantages include increased polythelene thickness, avoidance
of locking mechanisms issues and backside wear, less osteolysis and lower
cost. Disadvantages include limitations in term of options of wedges, stem
extensions and cementless fixation, no possibility for liner exchange in cases
of infection and instability and relatively difficult surgical technique.
CONDYLAR CONSTRAINED KNEE FIG. 15.5

Condylar constrained knee designs
are made to give coronal plane
(varus–valgus) stability to the
implant. They have a large rein-
forced post in tibial insert sitting in
a corresponding deep femoral cam.
Stem extensions are added to trans-
mit the load stresses from fixation
interface to the diaphysis. They are
indicated in severe valgus deformity
of knee, collateral deficiency, bone
defects, posttraumatic arthritis or
instability created by irreconcilable
flexion–extension gap balancing in
PS knees. In cases of flexion insta-
bility where increased flexion gap
Fig. 15.5 Condylar constrained knee. allows for posterior translation of
tibial component, use of a con-
strained condylar knee (CCK) implant may provide stability by increasing
the jump distance. However, the long-term results are under study and
increased bone loss and osteolysis are potential disadvantages (Fig. 15.6).
A B
Fig.15.6 Preoperative (A) and postoperative (B) X-rays of condylar constrained knee.
ROTATING HINGED KNEE PROSTHESES FIG. 15.7

They have a linked system, which
allows for both varus–valgus as well
as translational stability. They are
indicated for severe degrees of col-
lateral insufficiency and cases of
severe bone loss.
SPECIAL SITUATIONS
Complex primary cases in warrant-
ing TKA may present with severe
ligamentous laxity, posttraumatic
stiffness or flexion contracture or
malunion in proximal part of tibia
or distal part of femur with hardware
Fig.15.7 Rotating hinge knee.
in situ.
The challenge in such cases for the surgeon is to achieve rectangular
well-balanced flexion–extension gap. This situation can be best addressed
by using modular system that allows continuum constrain. With these
system options of constrain, augments and stem are available to surgeons
intraoperatively so that best outcome can be offered to the patient. Also it
is better to use posterior stabilizing knee prosthesis in these situations.
In case of a valgus knee where the medial collateral ligament is stretched
out and even after getting a rectangular flexion extension gap, the medial
side continues to remain lax on valgus strain, and a constrain type of knee
is recommended. Higher constraints are reserved to cases where it is not
possible to obtain final satisfactory balance: less than 5° of residual frontal
laxity in extension in each compartment, and a tibio-femoral gap differ-
ence not in excess of 3 mm between flexion and extension. Girard et al.34
in their study showed that ‘in choosing the level of constraint to be applied
in arthroplasty of a valgus knee deformity of more than 5°, it is important
to undertake preoperative radiographic quantifications of convex laxity, the
only independent parameter. The four other classical factors, identified by
univariate analysis (excessive tibial slope, low patella, valgus severity, valgus
of tibial origin), were not independent but their association should warn
even more surgeons about problems of ligament balancing. Respecting
these conditions should allow us to foresee, preoperatively with serenity,
the use of high-constraint prostheses for the treatment of knee arthropathy

with valgus deformity.’
Bone loss in total knee replacement provides a big challenge for the
surgeon and has to be addressed carefully. Thoughtful preoperative evalu-
ation and planning is most important as it will help to determine bone
graft and implant requirements, although provisions should always be there
for any change required on table. Extent and location of defect should be
assessed using radiography and even 3D CT scans if required. Depending
on the extent and location of the deficiency, there are many methods to
deal with them ranging from the use of PMMA cement with or without
screws for additional support, modular TKA systems with metal blocks
and wedges, augments and stems, constrained or rotating hinge prostheses
to mega or tumor prosthesis. Bone graft can be used as morcellised or
structural grafts using autograft or allograft material or bone substitutes.
Engh35,36 suggested that on the whole, choice of implant should be as
simple and unconstrained as possible. Where bone resection has restored
the stability, i.e., Anderson Orthopedic Research Institute (AORI) I, and
with a surface defect of less than 25% (50% of either tibial plateau or either
femoral condyle), primary implants can be used. However, whenever in
doubt, addition of a stem extension is always preferred. Use of a constrained
or hinged prosthesis is usually limited to severe soft tissue sleeve deficiency.
There are some proponents for uncemented implants, but general con-
sensus is for cemented implants. Augments are bone substitutes and space
fillers. They provide rotational stability in femur condylar or tibial plateau
deficiency or to restore the joint line. Stems provide about 20–30% of the
resistance to axial loading and help maintain rotational and axial stability.
They protect the bone graft material from excessive stresses and promote
incorporation. Metaphyseal sleeves and cones may be required in cases of
large central defects and give rotational stability, and in uncontained lesions
with deficient rim, they provide additional longitudinal and angular stabil-
ity. Use of highly porous coated sleeves is gaining popularity to fill defects
and facilitate biological fixation.
Pre-existing femoral or tibial extra-articular fracture deformity has
to be addressed with asymmetrical intra-articular resection or with cor-
rectional osteotomy performed prior to or at the time of primary TKA.
Careful preoperative planning is must. For fracture nonunion away from
the joint and presenting with arthritis of knee, the nonunion must be
addressed first followed by total knee replacement arthroplasty. For non-
unions within the vicinity of the knee and presenting with knee arthritis
warranting knee replacement surgery, a modular press-fit stem should be

used. It should serve two purposes: first, to bypass the fracture and pass the
load distally and second, to achieve optimal mechanical alignment. Tumor
replacement type of prosthesis is reserved for patients with significant bone
loss with very limited demand on the knee joint,where bone reconstruc-
tion is neither possible nor feasible.
SUMMARY AND CONCLUSION

Selection of implant should be based on the age of the patient, type of dis-
ease, amount of deformity, proper pre-op planning and anticipating intra-
operative difficulties. One should stick to a system in which the surgeon
is trained. Since PS metal back implants offer modularity and are more
forgiving, the consensus is shifting towards the trend of using it more com-
monly. The ultimate goal is to provide pain-free near-normal ROM with
longevity and long-term survival of implant.
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Cochrane framework. Acta Orthop 2005;76:757–68.
11. Tanzer M, Smith K, Burnett S. Posterior-stabilized versus cruciate retaining total knee
arthroplasty: balancing the gap. J Arthroplasty 2002;17:813–19.
12. Maruyama S, Yoshiya S, Matsui N, et al. Functional comparison of posterior

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13. Itokazu, M, Uemura, S, Aoki, T, et al. Analysis of rising from a chair after total knee
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14. Rowe PJ, Myles CM, Walker C, et al. Knee joint kinematics in gait and other func-
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is sufficient for normal daily life? Gait Posture 2000;12:143–55.
15. Swanik CB, Lephart SM, Rubash HE. Proprioception, kinesthesia, and balance after
total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses. J
Bone Joint Surg Am 2004;86A:328–34.
16. Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am
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17. Karrholm J, Saari T. Removal or retention—Will we ever know? The posterior cruci-
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34. Girard J, Amzallag M, Pasquier G, et al. Total knee arthroplasty in valgus knees: predic-
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Chapter 16
Tips and Pearls: Tourniquets

and Position in Total Knee
Arthroplasty
Kumar Kaushik Dash, Shrinand V. Vaidya, Arvind Arora
TOURNIQUETS
Introduction
From the days of the screw device of French surgeon Louis Petit in the
18th century (‘tourner’ being the French verb, meaning to turn) and the
rubber bandage of Johann von Esmarch, we have come a long way with
more refined calibrated and digitalized tourniquets with autoclavable cuffs.
Gone are the days when the pressure was increased blindly and there were
no guidelines for inflation duration. The advances in modern tourniquet
design and calibration have significantly reduced the amount of pressure and
the fluctuation from the set value. Improvements in surgical technique and
instruments have reduced the duration of surgery in most cases. And finally,
better understanding of human physiology under tourniquets has enabled us
to formulate significantly better guidelines regarding tourniquet use.
Like any medical appliance, tourniquet has certain risks and benefits.
Tourniquet provides a bloodless field, and a better cement bone interface.1
The risks include neuro-vascular injury, delay in recovery of muscle power,
postoperative swelling and stiffness, and cardiorespiratory complications
in patients with poor reserve.1 For beginners in arthroplasty, the authors
recommend using tourniquets in order to achieve a good exposure and
to be able to identify structures and cement–bone interface easily. The
tourniquet should be applied high up in the thigh, well padded and with
occlusive dressing at its margin, at a pressure of 250–300 mm Hg, for a
duration of 2–2.5 h.
Tourniquet use may alter the evaluation of patellar tracking because
inflated cuff of tourniquet pushes quadriceps against the femur and impairs
its mobility. Hence, at the end of the surgery, the tracking should be evaluated
both before and after the release of tourniquet. Certain surgeons use tourni-
Tips and Pearls: Tourniquets and Position in Total Knee Arthroplasty 205
quet only during cementing. Here tourniquet is used only for providing bet-
ter cement–bone interface and not for exposure of soft tissues. However, in
the absence of hypotensive anaesthesia, this approach is difficult for beginners.
Local tissue metabolites accumulated during tourniquet use can cause wors-
ening of postoperative pain. Using comparatively lower inflation pressure will
decrease its incidence. Using lower pressure is also important in patients with
nonelastic calcified atherosclerotic femoral vessels in order to avoid chance
of vascular injury, which should be seen on pre-op plain X-ray. Finally,
tourniquet use may alter the balance of coagulation mediators. Authors
recommend surgeons to be vigilant about this complication and administer
appropriate prophylaxis to prevent coagulation-related complications.
Method of Application
Hip should be widely abducted and flexed while applying tourniquet to
the thigh so that it goes as proximal to the base of the thigh as possible. In
patients with arthritic or ankylosed hips, this may be challenging. The tour-
niquet should be applied with adequate padding between the cuff and the
skin. There should be no areas without padding or with uneven folds. The
position should be as proximal as possible in order to have more freedom
during the surgery. The quadriceps should be pulled distally while applying
the tourniquet so as to make retraction and exposure during surgery easier.
Occlusive dressing should be used to seal off edges of tourniquet. This pre-
vents liquid seeping under the edge of tourniquet, which might cause chemi-
cal burns. Leg is flexed before inflation of the tourniquet to ensure relaxed
quadriceps (Figs 16.1–16.4).
Fig. 16.1 Soft cotton roll is applied on Fig. 16.2 Tourniquet applied snuggly
proximal thigh with hip being held in around the thigh, as proximal as possible,
wide abduction. ensuring that it is separated from the skin
at all sites by the soft padding.
Fig. 16.3 The tubing-attachment site on Fig. 16.4 The cuff is covered and secured
the cuff must be positioned laterally and by additional bandage rolls.
directed cranially.
Dimension and Design

With inputs from new research studies, a debate has arisen on shape and
size of tourniquets.2 Newer data has implicated pressure gradient at the
edge3 of tourniquet as the cause of nerve damage, suggesting that a nar-
rower cuff might lead to lesser risk. This has also sparked interest towards
the use of narrow, nonpneumatic silicone ring tourniquets.4,5 On the other
hand, some surgeons prefer wider cuff because it stops the flow of blood at
a relatively lower inflation pressure.6,7 As far as design or shape of tourniquet
is concerned, there are no research studies demonstrating benefit with any
particular type over others.
There are many commercially available tourniquet systems. Stryker
offers SmartPump tourniquet system (both single and dual channel),
which has three main features. First, it continuously monitors and con-
trols tourniquet pressure. Second, it communicates with OR software.
And finally, it allows pressure data collection that can be printed or added
to patient records. Zimmer also has similar products (e.g., A.T.S. 3000)
which calculate limb occlusion pressure (LOP) through a sensor in index
finger and sets the pressure accordingly. All reputable manufacturers pro-
vide color-coded cuff sizes ranging from small to large (8–42 inches). A
battery backup of 3–4 h is available for emergency power failure. Modern
cuffs are made of latex-free material, and are available in both reusable
and disposable format. They have 90° ports for keeping hoses out of sur-
gical site. Zimmer offers contour cuffs for better optimization to conical
limb sites. Hemaclear (OHK Medical Devices, Inc.) provides single use
all-in-one sterile exsanguinating tourniquet made up of stockinette and
silicon ring. The advantages are ease of use, narrow profile, smaller foot-
print in OR and no risk of contamination.
Special Situations
The authors recommend the readers to develop their tourniquet protocol
as per clinical needs. In a short limb, a narrow tourniquet applied high up
in the thigh is appropriate. When that cannot be achieved, sterile tourni-
quets or modern nonpneumatic silicone rings are other option. Disposable
sterile exsanguination tourniquet consists of a silicon ring wrapped by a
stockinette, which is rolled up from foot all the way up to the upper end
of thigh by pulling two straps. At the end of the surgery, the elastic ring at
the proximal end is cut with a scalpel to restore blood flow.8 In extremely
obese patients with conical thighs, banana-shaped tourniquets are better.
In bilateral simultaneous total knee arthroplasty (TKA), the tourniquet
cuff on both sides can be connected to the machine which has an in-built
mechanism to inflate the right and left cuff separately as and when required.
In this situation, the patient is positioned at the center of the table and side
supports of both sides are rotated slightly inwards so that both limbs remain
vertical in knee and hip-flexed position, and there is no sideway tilting of
the limb. This also helps to maintain the proper asepsis during surgery.
Inflation Time and Deflation Interval

The authors recommend inflation time to be set approximately at 2 h. The
decision regarding further continuation should be taken at the end of 2 h.
If based on the intraoperative scenario, the surgeon feels that the anticipat-
ed duration is going to be approximately less than 2 h, he/she may choose
to continue the inflation. On the other hand, if duration longer than 2 h
is anticipated, it is best to deflate the tourniquet for an interval of 10 min,
and repeat the deflation at every further 1 h intervals.
Inflation Pressure
The authors recommend a tourniquet pressure between 250 and 300 mm
Hg for TKA if the anticipated surgery duration is approximately less than
2 h. For situations where surgery may last longer, it is best to first measure
the LOP either by a commercial device or by a Doppler stethoscope, and
then use an inflation pressure that is 50–75 mm Hg higher than the LOP.
Newer tourniquet systems have an LOP sensor, which is applied to second
toe and it provides a recommended tourniquet pressure after 30 s. The
surgeon has the choice to accept the recommended pressure or change it.
The limb girth is also to be considered while deciding on inflation pressure,
with higher pressure required for wider girth.
Special Situations
The authors recommend the readers to develop their tourniquet protocol
as per clinical needs. In a short limb, a narrow tourniquet applied high up
in the thigh is appropriate. When that cannot be achieved, sterile tourni-
quets or modern nonpneumatic silicone rings are other option. Disposable
sterile exsanguination tourniquet consists of a silicon ring wrapped by a
stockinette, which is rolled up from foot all the way up to the upper end
of thigh by pulling two straps. At the end of the surgery, the elastic ring at
the proximal end is cut with a scalpel to restore blood flow.8 In extremely
obese patients with conical thighs, banana-shaped tourniquets are better.
In bilateral simultaneous total knee arthroplasty (TKA), the tourniquet
cuff on both sides can be connected to the machine which has an in-built
mechanism to inflate the right and left cuff separately as and when required.
In this situation, the patient is positioned at the center of the table and side
supports of both sides are rotated slightly inwards so that both limbs remain
vertical in knee and hip-flexed position, and there is no sideway tilting of
the limb. This also helps to maintain the proper asepsis during surgery.
Inflation Time and Deflation Interval

The authors recommend inflation time to be set approximately at 2 h. The
decision regarding further continuation should be taken at the end of 2 h.
If based on the intraoperative scenario, the surgeon feels that the anticipat-
ed duration is going to be approximately less than 2 h, he/she may choose
to continue the inflation. On the other hand, if duration longer than 2 h
is anticipated, it is best to deflate the tourniquet for an interval of 10 min,
and repeat the deflation at every further 1 h intervals.
Inflation Pressure
The authors recommend a tourniquet pressure between 250 and 300 mm
Hg for TKA if the anticipated surgery duration is approximately less than
2 h. For situations where surgery may last longer, it is best to first measure
the LOP either by a commercial device or by a Doppler stethoscope, and
then use an inflation pressure that is 50–75 mm Hg higher than the LOP.
Newer tourniquet systems have an LOP sensor, which is applied to second
toe and it provides a recommended tourniquet pressure after 30 s. The
surgeon has the choice to accept the recommended pressure or change it.
The limb girth is also to be considered while deciding on inflation pressure,
with higher pressure required for wider girth.
Calibration, Checking and Safety

Most modern tourniquet systems allow presetting of inflation pressure and
time. A microprocessor autoregulates the flow of compressed air in order
to self-compensate and constantly maintain the inflation pressure. Safety
mechanisms include a system to prevent inflation to very high pressures
(e.g., >600 mm Hg), and a failsafe method that maintains cuff pressure
when a leak occurs or gas supply is interrupted.
Failure of inflation and abnormal high pressure can occur if the valves
and pressure gauges are faulty. Routine calibration checks (preferably daily)
and monthly performance assurance tests should be done on all compo-
nents of a tourniquet system to ensure safe and effective functioning.
Complications
Postoperative local thigh pain is a minor but the most common complaint,
which usually settles after 2–3 days postoperative. Two factors are involved
in pathogenesis of tourniquet-related complications. Ischaemia causes
metabolic complications, whereas the mechanical compression causes nerve
and muscle damage. Nervous tissue is less vulnerable to tourniquet injury
compared to skeletal muscle, but the impairment is more long lasting com-
pared to similar injury in skeletal muscle. The incidence of peroneal and
tibial nerve palsy is more if inflation time is greater than 2.5 h.
Metabolic parameters affected by tourniquet use include lactic acid,
reactive oxygen metabolites, pH and glucose. After routine inflation dura-
tions, most of the parameters return to normalcy within 2–3 h. While there
is a higher chance of electromyography (EMG) changes and decreased
strength in quadriceps after 4 and 12 weeks from surgery, there is no differ-
ence between tourniquet and tourniquet-less groups at 1-year follow-up.2
Future of Tourniquets
Two main avenues of research are available in order to improve the tour-
niquet system. First is ‘better design’. For example, curved tourniquets
better fit the conical limbs and achieve occlusion at a lower inflation pres-
sure. Second is ‘smart tourniquets’. These incorporate microelectronics to
detect arterial flow and auto-adjust the inflation pressure. The other areas
of active research lie in better understanding of tissue physiology. Role of
n-acetylcysteine and similar compounds for preconditioning of tissues to
prevent ischaemia and reperfusion injury (IRI) is being evaluated.
POSITION
The operating table should be parallel to the ground with patient com-
fortably supine. The patient should be brought to the edge of the bed on
the operating side. Safety restraining strap should be in place. The side
support should be near the level of tourniquet. The vertical height of the
side support should be slightly higher in order to ensure that the knee
stays stable during flexion (Figs 16.5 and 16.6). The horizontal foot sup-
Fig. 16.5 The position of side-clamp is Fig. 16.6 The foot support is positioned
adjusted with knee in flexion. Notice that ensuring a 90° flexion at the knee joint.
the patient is at the edge of the table.
port should be fixed in a position that keeps the knee in 90° of flexion.
This offers steady limb position in most of the maneuvers during total
knee replacement (TKR), e.g., full knee flexion (heel to buttock), which
delivers tibial upper surface, or thigh up for femoral procedures.
REFERENCES
1. Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthro-
plasty. A prospective, randomised study. J Bone Joint Surg Br 1999;81(1):30–3. PubMed
PMID: 10067997.
2. Fitzgibbons PG, Digiovanni C, Hares S, Akelman E. Safe tourniquet use: a review of
the evidence. J Am Acad Orthop Surg 2012;20(5):310–19. doi: 10.5435/JAAOS-20-05-
310. Review. PubMed PMID: 22553103.
3. Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral nerves compressed
by a pneumatic tourniquet. J Anat 1972;113(pt 3):433–55.
4. Gavriely N. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am 2010;92(5):
1318–23.
5. Drosos GI, Stavropoulos NI, Kazakos K, Tripsianis G, Ververidis A, Verettas DA.
Silicone ring versus pneumatic cuff tourniquet: A comparative quantitative study in
healthy individuals. Arch Orthop Trauma Surg 2011;131(4):447–54.
6. Crenshaw AG, Hargens AR, Gershuni DH, Rydevik B. Wide tourniquet cuffs more
effective at lower inflation pressures. Acta Orthop Scand 1988;59(4):447–51.
POSITION
The operating table should be parallel to the ground with patient com-
fortably supine. The patient should be brought to the edge of the bed on
the operating side. Safety restraining strap should be in place. The side
support should be near the level of tourniquet. The vertical height of the
side support should be slightly higher in order to ensure that the knee
stays stable during flexion (Figs 16.5 and 16.6). The horizontal foot sup-
Fig. 16.5 The position of side-clamp is Fig. 16.6 The foot support is positioned
adjusted with knee in flexion. Notice that ensuring a 90° flexion at the knee joint.
the patient is at the edge of the table.
port should be fixed in a position that keeps the knee in 90° of flexion.
This offers steady limb position in most of the maneuvers during total
knee replacement (TKR), e.g., full knee flexion (heel to buttock), which
delivers tibial upper surface, or thigh up for femoral procedures.
REFERENCES
1. Wakankar HM, Nicholl JE, Koka R, D’Arcy JC. The tourniquet in total knee arthro-
plasty. A prospective, randomised study. J Bone Joint Surg Br 1999;81(1):30–3. PubMed
PMID: 10067997.
2. Fitzgibbons PG, Digiovanni C, Hares S, Akelman E. Safe tourniquet use: a review of
the evidence. J Am Acad Orthop Surg 2012;20(5):310–19. doi: 10.5435/JAAOS-20-05-
310. Review. PubMed PMID: 22553103.
3. Ochoa J, Fowler TJ, Gilliatt RW. Anatomical changes in peripheral nerves compressed
by a pneumatic tourniquet. J Anat 1972;113(pt 3):433–55.
4. Gavriely N. Surgical tourniquets in orthopaedics. J Bone Joint Surg Am 2010;92(5):
1318–23.
5. Drosos GI, Stavropoulos NI, Kazakos K, Tripsianis G, Ververidis A, Verettas DA.
Silicone ring versus pneumatic cuff tourniquet: A comparative quantitative study in
healthy individuals. Arch Orthop Trauma Surg 2011;131(4):447–54.
6. Crenshaw AG, Hargens AR, Gershuni DH, Rydevik B. Wide tourniquet cuffs more
effective at lower inflation pressures. Acta Orthop Scand 1988;59(4):447–51.
7. Reilly CW, McEwen JA, Leveille L, Perdios A, Mulpuri K. Minimizing tourniquet

pressure in pediatric anterior cruciate ligament reconstructive surgery: a blinded,
prospective randomized controlled trial. J Pediatr Orthop 2009;29(3):275–80.
8. Demirkale I, Tecimel O, Sesen H, Kilicarslan K, Altay M, Dogan M. Nondrainage
decreases blood transfusion need and infection rate in bilateral total knee arthroplasty.
J Arthroplasty 2014;29(5):993–7. doi: 10.1016/j.arth.2013.10.022. Epub 2013 Oct 29.
Conflict of Interest: The names of commercial parties mentioned in this chapter are purely for educa-
tional purpose; and authors do not recommend or condone any particular manufacturer.
Chapter 17
Tips and Pearls: Exposure

and Retractors in Total Knee
Arthroplasty
Shrinand V. Vaidya, Kumar Kaushik Dash
EXPOSURE
Basics of Knee Exposure

There are many ways to expose the knee. There are three layers, viz., skin
incision, capsular incision (arthrotomy) and quadriceps mechanism incision.
Essentially, all the approaches described in the literature revolve around
combination of these (see Figs 17.1 and 17.2).
Approaches to Knee
Lateral Arthrotomy Medial Arthrotomy

Approach* Approach
Non-MIS
MIS (Medial Parapatellar Von
Langenbeck/Modified
Langenbeck)
Subvastus Trivector Midvastus Quad Sparing
*Some surgeons prefer it in valgus knees.
Fig. 17.1 Classification of knee approaches.

Von Langenbeck 1879

Non-MIS
Skin Capsule Quadriceps
Medial 1/3rd-2/3rd
Standard Variations In presence of scars
Fig. 17.2 Skin, capsule and quadriceps breakdown of Von Langenbeck incision.
Medial parapatellar approach is the most common approach, originally

described by Von Langenbeck in 1879. It has demonstrated excellent track
record and has proven its reliability, safety and reproducibility over the last
four decades. Its advantages are excellent visualization, extensile, easy release
of medial structures in severe varus deformity, very reliable and reproduc-
ible. The disadvantage is violation of extensor mechanism.
Skin incision, when restricted to 5 inches or less1 is called MIS or
minimally invasive surgery. Depending upon the way the suprapatellar part
of quadriceps mechanism is handled, the MIS approaches are divided into
subvastus, midvastus, trivector and quadriceps sparing.
Incidence of wound complications in some series is 22%. It occurs
more in knees because of precarious blood supply. Vascular anatomy of
knee involves terminal branches of peripheral anastomosis between supe-
rior lateral genicular artery (SLGA), inferior lateral genicular artery (ILGA),
superior medial genicular artery (SMGA) and inferomedial genicular artery
(IMGA). Saphenous branch of descending geniculate and lateral geniculate
are the main venous drainage of the area. No underlying muscle or inter-
muscular septae makes this area highly susceptible to wound complications.
Because the anastomoses are superficial to fascia, subfascial dissection is
required to preserve blood supply.
Tips and Pearls: Exposure and Retractors in Total Knee Arthroplasty 213
Risk factors for wound complication are:2–4

1. Decreased fibroblast proliferation
2. Reduced collagenase clearance and reduced tensile strength
3. Rheumatoid arthritis
4. Smoking
5. Diabetes
6. Obesity
7. Vigorous retraction
8. Malnutrition
9. Albumin less than 3.5 g/dL
10. Total lymphocyte count (TLC) less than 1500/mm3
11. Chemotherapy
12. Burned irradiated skin
13. Previous surgical incision
We will describe the Langenbeck approach with standard anteromedial
arthrotomy, because it is largely followed world over by most of the arthro-
plasty surgeons.
Surgical Technique
Knee is prepped and draped as shown
in the diagram (Fig. 17.3), and impor-
tant anatomic surface landmarks are
marked. The three important points
are the tibial tuberosity, patella and its
centre. Usually, this is very easily iden-
tifiable, but in an obese patient, it may
be difficult to find the exact location
of the tibial tubercle. Skin incision can
be taken erroneously as per guided by
the drape by many young surgeons,
and this will lead to totally off-center
incision, only to locate tibial tubercle
somewhere else, resulting into messy
retractions, and badly extended skin
incision, to visualize inner landmarks.
Fig. 17.3 Knee prepped and draped with
While choosing the single anterior markings of landmarks and skin incisions.
incision, midline incision causes least Note previous parallel scars 7 and 8 cm
disruption of the blood supply.5 When away on either side.
there are previous surgeries done, it is best to utilize the previous incisions.6
It is safe to ignore short peripatellar longitudinal incisions of arthroplasty.7
Transverse incisions may generally be crossed at right angles with impunity.8
If more than one longitudinal incisions exist, choose the most lateral incision.
Large laterally based skin flaps should be avoided.9 Hence, if scar is far from
midline, consider a new midline incision. For intersecting incisions, always
try to maximize the angle of intersection (should be more than 60°). Acute
or suddenly changing angles should be avoided. The width of skin bridge
between incisions should be adequate (8 cm – Mont, 5 cm – Ranawat, 2.5
cm – Rand).10–12 Excessive tension in incision should be avoided and in this
regard, longer skin incisions are better than shorter. Retraction of skin should
be gentle to protect fasciocutaneous perforators. Large flaps should be avoided.
Mark the center of tibial tuberosity and center of patella and join them.
Proximally, the incision, as originally described, goes 7 cm proximal to
upper pole of patella. However, many now prefer to keep it shorter, and
extend as per requirement.
The distal end of the skin incision is extended distally, as per the conve-
nience of surgeon than the fixed predecided length. Scuderi has clearly talked
about the V sign.13 If you feel that both ends of the skin are getting so much
taut that there is an obtuse angle (U Sign) (see Figs 17.4 and 17.5), the ten-
sion is high enough to damage the blood flow to edge of the skin, increasing
the potential for problems of wound healing.
Surgeon should be at liberty to increase the size of the skin incision
depending on the patient and pathology, so as to facilitate better introduction
Fig. 17.4 Lower end of the incision get- Fig. 17.5 After extending lower end of
ting stretched after putting retractors – ‘U’ incision till ‘V’ appears as marked.
sign.
of the jigs and saw. Above all, he is able to close the wound that is going to
heal with primary intension without any problems.
After the incision, without much undermining, try to clearly define
the following points: the fleshy belly of patellar tendon, the medial mar-
gin of patella and the central tendon (note the fibers of vastus medialis
coming from all angles and getting inserted on the central tendon, i.e.,
superior, superomedial and medial). The bulk and direction and inser-
tion angle of vastus medialis can differ from patient to patient. Suffices
to say that the whitish central tendon should be clearly defined. Marking
should be done before incising quads to help with closure (prevents dog-
ears). Most of the times, there is extension lag because of the failure to
approximate the margins of quads as per the preoperative anatomic status.
Arthrotomy should be performed, around medial edge of patella,
leaving about 5 mm of reticular attachment, to the medial border, with
skin knife at 30° angle to coronal plane, with knee joint flexed at 60°.
Incision is carefully extended up, between medial one-third and lateral
two-thirds of the central tendon of quadriceps. We have stopped incising
the central tendon since last decade or so, and instead spared the central
tendon, by going midvastus, keeping 5 mm of fleshy belly of vastus intact
on medial side. The incision may be extended up to about 5–7 cm proxi-
mal to the upper pole of patella.
Sparing of the quadriceps, central
tendon has definitely resulted in
early recovery without extension
lag. The proximal extent is kept
about 7 cm above the superior pole
of patella, which again may differ
from surgeon to surgeon. Distally,
after curving around, patella may
go down till periosteum of tibia,
making sure that there is always 3–4
mm of cuff of retinacular soft tissue
adjoining the patellar tendon.
Authors’ Choice
We have shortened skin incision,
much less than Langenbeck, and is
usually 5–6 inches (see Fig. 17.6). Fig. 17.6 Figure showing authors’ choice
of skin incision with length of 5 inches.
The length is kept adequate so

that the ‘U’ sign at the ends of the
incision is avoided. We also liber-
ally elongate the incision, as per the
demand in the obese patients.
After the arthrotomy is complete,
keep on going medially in the sub-
capsular plane of the tibia while ask-
ing the assistant to externally rotate
the tibia, and proceed with a cutting
cautery at the edge along subperios-
teal plane. Introduce the tip of medial
collateral ligament (MCL) retractor
(see Figs 17.7 and 17.8) subperioste-
ally and underneath the MCL in the
plane of semimembranosus bursa.
Hold and pull the anterior horn
of the medial meniscus with a menis-
Fig. 17.7 Specially designed and curved
cal holding forceps (see Fig. 17.9), to
medial collateral ligament retractor.
detach it carefully from the menisco-
tibial ligament, on its periphery all around, with utmost care, not to let the
cutting err on the outer side, i.e., the side of MCL.
Many a times, it may not be possible to remove medial meniscus
completely, as it may be ejected in the posteromedial corner of the tibia,
as a part of arthritic process. Complete the ‘Ransall maneuver’ (named
after Dr Ranawat and Dr Insall). Take a curved, three-eighths-inch osteo-
tome and pass it around the medial
corner of the tibia using mallet
to tap it back until it drops into
the semimembranosus bursa. The
interval is at the joint line between
the tibial bone and the deep MCL.
Osteophytectomy is done starting
from 6 O’clock position, all around
from medial side, and then postero-
medially, both on the tibial as well Fig. 17.8 Medial collateral retractor, intro-
as femoral side, in a typical varus duced subperiosteally along semimebra-
arthritis. The retractor can be repo- nosus bursa between medial collateral
sitioned along the medial edge of ligament (MCL) and medial edge of tibia.
tibia, underneath the superficial MCL, which by now is completely decom-

pressed from the tenting effect of the osteophytes. This step safely protects
it from saw blade and facilitates cementing. The shape of the retractor,
which author uses, is kept such, so as to have assistant’s hands holding this
retractor, away from the surgical field, almost at the back of the knee, in
coronal plane.
Next anterior cruciate ligament is removed (if intact), and the tibia is
rotated externally and dislocated forward in relation to femoral condyles. A
retractor with the angle around 60° (see Figs 17.10 and 17.11 ) comes very
handy. Because the angle, when lessened from 90° to 60°, offers better offset
to jack tibia anteriorly, even in the obese patients. The tip of the posterior
retractor is inserted at the back of the tibial margin, leveraging against the
intercondylar area of the femur, to get full view of the tibia from the top.
Using a no. 15 blade, a stab wound is made just outside the lateral menis-
Fig. 17.9 Anterior horn of the medial

meniscus detached and being held with
forceps.
Fig. 17.10 Lateral retractor with 60° angle. Fig. 17.11 View from the top showing
medial, lateral, posterior retractors with
360° exposure of tibia.
cus at the mid-coronal plane of the tibia. A modified Hohmann retractor (see
Fig. 17.12) specially modified is used for this purpose. With shortened tooth
and narrower vertical arm, we feel it lessens the postoperative pain in this
area, and thus, is less traumatic. After identifying the lateral inferior genicul-
car artery, which is located on the outer rim of the meniscus at about mid
coronal plane, it is coagulated. Patellar articular surface is inspected. If there
are too many osteophytes, spontaneous decision is taken to nibble the osteo-
phytes, but in no case should the patella be everted, as it used to be before.
There is evidence that tells us that noneverted patella is associated with less
pain, less extension lag and early rehabilitation.14 In case there is a difficulty to
retract patella without everting, a narrow fold of synovium, ‘patello femoral
ligament’ (see Fig. 17.13) is released with a cautery.
Effort should be made to keep the lateral retractor vertical, and not to try
and over stretch it, as this may put pressure on the patellar tendon insertion. If
there is a stretch on patellar tendon insertion, very commonly in osteoporotic
patients, it is worthwhile transfixing it with a pin.
Next step is to remove the lateral meniscus, starting from the anterior tip,
which is pulled centrally, while cautery goes all around the lateral menisco-
tibial ligament (see Fig. 17.12). Caution on the lateral side is to avoid any
injury to the popliteal tendon, which may be hypertrophied and can be cut
by mistake.
Now, with these three retractors in place (Fig. 17.11 ), we have 360°
exposure of the tibia, as well as femur. Surgeon may proceed with either fem-
oral or tibial cut first, as per the individual choice. In case, femoral cut is done
Fig. 17.12 Lateral retractor in place after the stab in mid-

coronal plane and lateral meniscus detached.
Fig. 17.13 Lateral patellar retractor in place and

showing patellofemoral ligament at cautery tip.
first, especially with minimally invasive surgery (MIS) instruments, patella is

best protected and retracted out with the retractor shown in Fig. 17.13.
MIS approaches, namely, subvastus, midvastus, trivector and quadriceps
sparing (see Fig. 17.14), essentially were conceptualized with the premise
that it will reduce the postoperative pain and bleeding and will allow the
patient to ambulate faster, and result in early discharge.15,16
The key element is the suprapatellar extension of the arthrotomy and
the direction surgeon may have to take to elevate and rotate the quadriceps
bulk, from medial to lateral side. Though conceptually appealing, there
Fig. 17.14 The different capsular incision extending into quadriceps mechanism is
shown. From left to right: Langenbeck, subvastus, midvastus, quad-sparing.
have been significant disadvantages. The torque generated during retraction

in the quadriceps mechanism may compel jigs to rotate and cause malalign-
ment. The space constraint may also damage the nerve fibres supplying the
quadriceps mechanism. These reservations together with lesser blood loss
because of tranexamic acid and injecting locally for pain management have
lessened the initial enthusiasm for MIS.17 Since this book is recommended
for beginners, we advise the readers to go through the recommended
reading at the end of the chapter, as a guidance to expose the knee joint
through smaller incisions.
The set of retractors that the author uses has been shown in Figure 17.15.
Fig. 17.15 Set of retractors, which the authors use.
REFERENCES
1. Lin TC, Wang HK, Chen JW, Chiu CM, Chou HL, Chang CH. Minimally invasive
knee arthroplasty with the subvastus approach allows rapid rehabilitation: a prospec-
tive, biomechanical and observational study. J Phys Ther Sci 2013;25(5):557–62. doi:
10.1589/jpts.25.557. Epub 2013 Jun 29. PubMed PMID:24259801; PubMed Central
PMCID: PMC3804974.
2. Carroll K, Dowsey M, Choong P, Peel T. Risk factors for superficial wound com-
plications in hip and knee arthroplasty. Clin Microbiol Infect 2014;20(2):130–35. doi:
10.1111/1469-0691.12209. Epub 2013 Apr 10. PubMed PMID:23573834.
3. Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Relat Res
2006;452:88–90. Review. PubMed PMID: 17079990.
4. Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD.
Surgical treatment of early wound complications following primary total knee arthro-
plasty. J Bone Joint Surg Am 2009;91(1):48–54. doi:10.2106/JBJS.G.01371. PubMed
PMID: 19122078.
5. Johnson DP, Houghton TA, Radford P. Anterior midline or medial parapatellar incision
for arthroplasty of the knee. A comparative study. J Bone Joint Surg Br 1986;68(5):812–
14. PubMed PMID: 3782252.
6. Ayers DC, Dennis DA, Johanson NA, Pellegrini VD. Instructional course lectures: The
American Academy of Orthopaedic Surgeons. Common complications of total knee
arthroplasty. J Bone Joint Surg Am 1997;79:278–311.

7. Klein NE, Cox CV. Wound problems in total knee arthroplasty. In: Fu FH, Harner CD,
Vince K, eds. Knee Surgery. Baltimore: Williams & Wilkins, 1994; pp.1539–52.
8. Windsor RE, Insall JN, Vince KG. Technical considerations of total knee arthroplasty
after proximal tibial osteotomy. J Bone Joint Surg Am 1988;70(4):547–55. PubMed
PMID: 3356722.
9. Clarke HD, Scuderi GR. Revision total knee arthroplasty: planning, management, con-
troversies, and surgical approaches. Instr Course Lect 2001;50:359–65. Review. PubMed
PMID: 11372334.
10. Sanna M, Sanna C, Caputo F, Piu G, Salvi M. Surgical approaches in total knee arthro-
plasty. Joints 2013;1(2):34–44. ISSN: 2282-4234.
11. Garbedian S, Sternheim A, Backstein D. Wound healing problems in total knee arthro-
plasty. Orthopedics 2011;34(9):e516–18. doi:10.3928/014774.
12. Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Relat Res
2006;452:88–90.
13. Scuderi GR. Patient-based MIS TKA: for everything there is a season. Orthopedics
2008;31(9):923–24.
14. Majima T, Nishiike O, Sawaguchi N, Susuda K, Minami A. Patella eversion reduces
early knee range of motion and muscle torque recovery after total knee arthroplasty:
comparison between minimally invasive total knee arthroplasty and conventional total
knee arthroplasty. Arthritis 2011;2011:854651. doi:10.1155/2011/854651. Epub 2010
Dec 29. PubMed PMID: 22046526; PubMed Central PMCID: PMC3195321.
15. Li C, Zeng Y, Shen B, Kang P, Yang J, Zhou Z, Pei F. A meta-analysis of minimally
invasive and conventional medial parapatellar approaches for primary total knee arthro-
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24448689.
16. Tasker A, Hassaballa M, Murray J, Lancaster S, Artz N, Harries W, Porteous A.
Minimally invasive total knee arthroplasty; a pragmatic randomised controlled trial
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knee.2013.07.010. Epub 2013 Aug 2. PubMed PMID: 23972565.
17. Unnanuntana A, Pornrattanamaneewong C, Mow CS. Minimally invasive and standard
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Chapter 18
Tips and Pearls: Saw Technique

in Total Knee Arthroplasty
Shrinand V. Vaidya, Kumar Kaushik Dash
Saw technique is the key element of total knee replacement surgery. Wrong
or inefficient saw cut can lead to erroneous seating of any one or all the three
components, which in turn can lead to error in the knee joint alignment
and/or balancing. The surgeon who masters the saw technique (both in
understanding the way it cuts and also in learning how to protect ligaments
and neurovascular structures) can optimize the surgical time of the knee
replacement surgery. This has a major effect on his result, as the time required
to finish off a surgery has direct bearing on the surgical site infection.
It is important to understand the concept of effective sharpness and
cutting efficiency.1 The saw speed, which is controlled by the grip button,
and oscillatory movements of the teeth require continues monitoring. The
surgeon should decide the forward progress based on the tactile feedback
that he gets on his grip during the passage of the cut in bone.
There is very little scientific literature on the saw technique apart from
the information provided by manufacturers. But it is important to under-
stand that saw technique itself is a different kind of bio-skill. A newcomer
requires some guidance as to how to handle the saw, which blades to use
for a particular cut and how to be efficient but safe, as the saw can endan-
ger major ligaments, if handled carelessly. Hence, it is very important that
beginners master the saw techniques quickly. A dedicated bio-skill work-
shop, with ample practice bones can be a great facilitator, before operating
independently.
Essentially there are two types of saw handles – pneumatic and power
or battery saws. Pneumatic saws were first to arrive in the marketplace
and supposed to be safer, as they ideally should not damage the soft tis-
sue. However, because of cumbersome handling, with long pneumatic
hoses causing hindrance for surgeon’s efficient hand movements, battery-
operated saws have largely been preferred over the pneumatic by most
of the users world over. There are dos and don’ts for the maintenance
of disposable batteries and charger units, and autoclaving and sterile
Tips and Pearls: Saw Technique in Total Knee Arthroplasty 223
techniques, which can best be understood by talking to the company’s

product specialist. From the surgeon’s perspective, it is important to start
surgery only after knowing that at least four to six batteries are fully
charged before starting the surgery.
There are certain saw blade numbers that are very popular (e.g.,
Stryker Blade No. 2108-102, 2108-118, 2108-109, 2108-150, 2108-155,
2108-185). These denote different types of teeth configuration, thick-
ness of the blade, and length and width of the blade.
Stryker Corporation, Kalamazoo, MI, USA offers three types of sagittal
blades, viz., System 6, Dual Cuts and 2108. Three patented tool mounts are
available – System 6, System 5/4 and System 2000.
BLADE SHAPE
The shape of the cutting edge has a huge influence on the stability and
controllability of the blade. Kicking or grabbing causes loss of accuracy
in the cut from sudden, unpredictable movements of the saw and causes
increased surgeon fatigue because of the greater tension that the surgeon
must maintain in his hands and arms in the anticipation of receiving this
kicking or grabbing motion. A blade that is kicking back is neither safe
nor accurate (see Fig. 18.1).
It is easy to cut chamfer/notch cuts with the narrow blade, as narrower
blades work effectively and sharply. Longer blades work less effectively
at their tips as the work arm length increases. However, with a powerful
battery, they can make a very meaningful and efficient cut in one stroke.
Depending on the kind of jigs available (slit jigs with saw capture is less
likely to give rise to an error than platform jig), one can cut the anterior
and posterior chamfer cuts with narrow saw blade. The recommendations
by the manufacturers (Stryker Inc., USA) for various knee systems, which
match their latest saw system, are as per the chart (see Fig. 18.2).
Another important tip is for deciding the type of saw blade to be used
for a particular cut. It is much like a golfer choosing an appropriate club,
suitable for a particular shot! Some surgeons are very fond of reciprocating
saw blade, especially for cutting the intercondylar notch (and the author is
part of this group) which is the key-cut, prone to an error in the PS knee
design. If the cut goes in extension or flexion, one can land up with a mas-
sive error in component positioning and then balancing. It is important to
watch the progress of the saw from the profile and front to catch errors,
before any wrong cut is made. Nonoperating hand can help to monitor the
progress and guide the direction of the saw blade.
Warning!
The surgeon’s skill in saw technique is tested to the maximum when the
bone is either marble hard or very soft and osteoporotic. Many a times, we
experience marble hard bone on the medial side in case of varus deformity,
which is the load bearing side. This tough resistance by the bone will not
allow the saw to progress smoothly and the saw tip may move away in an
altogether different direction than the intended one – often referred to as
‘skiving.’
Blade Shape
Convex Straight Concave
Least Stable Intermediate. Better than Most Stable

Convex
Progressive engagement Concave shape creates a

All teeth engage bone at cutting face that keeps
the same time. This causes of cutting teeth. Reduces
cutting force and kick out. blade centred at all times
the tendency for the and allows the smoothest
blade to kick out during Allows user better control cut possible. Fewer teeth
the cut. of saw. Improved control engaged means blade does
allows faster cutting not grab or kick.
Fig. 18.1 Different configuration of saw tips (Courtesy: Stryker Inc., USA).
Capture System 6 Recommendation Dual Cut Recommendation Precision

Thickness
mm (inch)
AESCULAP
TKR SYSTEMS
Columbus 1.27 (.050) 6113-127-090 6118-127-090 4125-127-090 4118-127-090 Yes
BIOMET
TKR SYSTEMS
AGC
Maxim
Asent 1.37 (.054) 6125-137-090 6118-137-090 4125-137-090 4118-137-090 Yes
Vanguard
Finn
UNI SYSTEMS
Repicci 1.37 (.054) 6125-137-090 6118-137-090 4125-137-090 4118-137-090 Yes
Vanguard 1.37 (.054)
Performance 1.07 (.042) 6113-107-090 4111-107-090 No
BIOPRO
TKR SYSTEMS
Townley 1.47 (.058) 6125-147-090 4125-147-090 4118-147-090 Yes
CORIN
TKR SYSTEMS
Nuffield 1.27 (.050) 6113-127-090 6118-127-090 4125-127-090 4118-127-090 Yes
Rotaglide 1.27 (.050)
DEPUY
TKR SYSTEMS
P.F.C. Sigma 1.19 (.047) 6118-119-090 4111-119-090 4118-119-090 No
LCS Complete 1.47 (.058) 6125-147-090 4125-147-090 Yes
UNI SYSTEMS
Preservation 1.27 (.050) 6113-127-090 6118-127-090 4125-127-090 4118-127-090 Yes
AMK, RHK, S-ROM 0.89 (.035) 6113-089-090 6118-089-090 4111-089-090 4118-089-090 No
S-ROM 0.89 (.035)
ENCORE (DJO)
TKR SYSTEMS
Foundation 1.0 (.039) 6125-097-090 6118-097-090 4125-127-090 4118-127-090 No
3D Knee 1.0 (.039)
UNI SYSTEMS
Mitus CONTAINS
NO
CAPTURES
Fig. 18.2 Manufacture-wise compatibility of saw blades (Courtesy: Stryker Inc., USA).
A B
Fig. 18.3 (A) Skiving at posterior edge of the femoral condyle. (B) Skiving corrected by
engaging saw blade.
Skiving can cause a variety of problems; commonest amongst them

can be:
1. Distal femoral cut: the component can malposition in extension because
of the hard resistance offered by the edge of the posterior condyle of
the femur (see Fig. 18.3A and B).
2. Residual tibial varus due to hard bone ridge left on the lateral tibial
margin, when saw skives up during tibial cut as it reaches lateral bor-
der (see Fig. 18.4A and B).
Warning!
The skiving is mainly due to three reasons:
1. The hardness of the bone, which offers significant resistance.
2. The mismatch between the diameter of bone to be cut, and the width
of saw blade tip.
3. The poor saw power, due to an exhausted battery.
A B
Fig. 18.4 (A) Skiving of the saw blade at lateral tibial edge. (B) Skiving corrected by re-
engaging the blade.
Fig.18.5 Potato-grating effect comparable Fig. 18.6 Efficient saw progress by

to progress of saw blade. approaching ‘acute angle.’
The trick to mitigate this problem is called ‘forward-backward tech-

nique.’ When facing abnormal resistance in the bone, it is important to
remember that one of the angles of the saw blade, instead of the whole of
the front toothed edge of the blade, should be introduced by rotating the
saw handle – something which is like a ‘potato-grating effect’ described
by Krackow1 (see Fig. 18.5). When a potato is peeled, the cook does not
shove the sharp edge of the peeler directly on the previous cut. Instead, to
continue peeling smoothly, the sharp edge of the peeler is brought at an
acute angle (half the breadth of the peeler on the cut surface and the rest
half on the uncut) to the raw surface, which minimizes the force required
to proceed effortlessly. This is done subconsciously as a matter of practice
and is worth implementing in the saw technique.The essence of this idea is
to approach the area to be cut at an acute angle, edge between already cut
and newer cut by rotating the potato (Fig. 18.6) to decrease the resistance.
So it is important to not frustrate your effort by banging saw blade’s blunt
end against the part when there is no progress. Instead, retract backwards
and reset the blade on the jig. Go on one side at an angle so that one of
Fig. 18.7 Rotating saw handle laterally and medially so that angle of the tip of the blade
causes efficient progress.
the angles of the edge, and not the full breadth of the teeth, is introduced.
Go to the opposite direction, in a Y-fashion and finally the center mound
(see Fig. 18.7A and B). This little trick makes the progress surprisingly
smoother and cut as desired. Also, steady stream of saline at the cut site
lubricates and minimizes the heat-related necrosis of bone. It also increases
the life of the saw by reducing the back thrust on the gears of saw. Progress
of a saw blade is not done by brute force in a linear fashion. Instead, go on
either side alternately by rotating the saw grip in coronal plane, roughly by
about 45°, and making repeated Y cuts, almost like a Christmas tree.This
guarantees headway even in the most stubborn bones.
Finally, whenever the saw blade is approaching a blind alley, it is impor-
tant to protect the area with either readymade metal protectors or simply a
broad osteotome or a retractor. This is particularly important in osteopo-
rotic patients because an unwarranted cut in either of the condyles due to
unchecked progress of the blade can lead to condylar fractures. In general,
once a surgeon realizes that bone is too soft and osteoporotic, saw power
should be toned down by releasing the power grip button appropriately.
Using the saw on patella demands special care, and it is strongly recom-
mended that the beginners use patella holders provided by the manufactur-
ers, as control is better and the patella is stable. Free hand technique with
the help of towel clips needs a lot of practice and can be erroneous if one
has to recreate the patellar thickness.
Efficient saw technique can significantly reduce the operating time and
can easily differentiate between a master and a commoner! For further
reading, the author recommends young surgeons to refer to other related
articles.2–6
REFERENCES
1. Krackow KA. The technique of total knee arthroplasty. Mosby 1990:220–37.
2. Hofmann AA, Bachus KN, Wyatt RW. Effect of the tibial cut on subsidence follow-
ing total knee arthroplasty. Clin Orthop Relat Res 1991;(269):63–9. PubMed PMID:
1864058.
3. Bäthis H, Perlick L, Tingart M, Perlick C, Lüring C, Grifka J. Intraoperative cutting
errors in total knee arthroplasty. Arch Orthop Trauma Surg 2005;125(1):16–20. Epub 2004
Nov 9. PubMed PMID: 15538589.
4. Plaskos C, Hodgson AJ, Inkpen K, McGraw RW. Bone cutting errors in total knee
arthroplasty. J Arthroplasty 2002;17(6):698–705. PubMed PMID: 12216022.
5. Tsukeoka T, Tsuneizumi Y, Lee TH. The effect of a sagittal cutting error of the distal
femur on the flexion-extension gap difference in total knee arthroplasty. J Arthroplasty.
2013;28(7):1099–102. doi: 10.1016/j.arth.2012.12.017. Epub 2013 Mar 20. PubMed
PMID: 23523491.
6. Tsukeoka T, Tsuneizumi Y, Lee TH. The effect of the posterior slope of the tibial pla-
teau osteotomy with a rotational error on tibial component malalignment in total knee
replacement. Bone Joint J. 2013;95-B(9):1201–03. doi:10.1302/0301-620X.95B9.31775.
Conflict of Interest: The names of commercial parties mentioned in this chapter are purely for educa-
tional purpose; and authors do not recommend or condone any particular manufacturer.
Chapter 19
Principles: Alignment and

Balancing
Hemant Wakankar
INTRODUCTION
Total knee arthroplasty (TKA) is one of the most successful surgical proce-
dures with over 90% survival rate at 10 to 15 years.1–4 However, the inci-
dence of early failure following TKA is as high as 4% to 20%.5,6 Excluding
infection, malalignment and instability are the two most important causes
of an early revision. It is therefore important to address the issues related to
achieving the alignment and balance during the surgical procedure of TKA.
BASIC PRINCIPLES OF ALIGNMENT

The mechanical axis of lower limb is the line joining the center of the hip
joint to the center of the ankle joint and normally passes through the center
of the knee joint (Fig. 19.1). In a well-aligned normal knee, both medial and
lateral knee compartments do get loaded almost equally. Biomechanically,
such a knee has equal distribution of forces over both knee compartments
and as a result is less likely to wear due to mechanical imbalance.
In patients who have a varus deformity, medial compartment of the
knee gets loaded excessively and is a major contributing factor, leading to
medial compartmental arthrosis. Similar situation exists in a valgus knee
where lateral compartment gets loaded excessively and develops lateral
compartment arthrosis.
The aim of TKA is to reproduce the mechanical axis that passes through
the central third of the knee. Many studies assessing the alignment following
TKA have shown the overall distribution to be the bell curve. The outlier
beyond the 3° of neutral axis have shown higher rate of revisions due to wear.
Normal tibia has 3° of physiological varus and the mechanical axis is at
3° to the vertical axis (Fig. 19.1). Some surgical techniques describe rec-
reating this varus deformity during surgery; however, this runs the risk of
excessive load on the medial compartment, leading to an early failure. It is,
Principles: Alignment and Balancing 231
Fig. 19.1 Mechanical axis passes through the center of the knee.
therefore, not attempted to reproduce the anatomical tibial resection but

the tibial resection is done perpendicular to its long axis.
Surgical Considerations of Mechanical Axis

The mechanical axis can be considered to have three segments: femoral
part, intra-articular part and tibial part. Every step of the surgical proce-
dure aims to get this mechanical axis correct. The distal femoral resection
is perpendicular to the mechanical axis. Most instrumentation systems use
medullary canal as reference (anatomical axis of femur), and therefore, the
angle between the medullary canal and the mechanical axis can be mea-
sured and set during surgery for distal femoral resection. In most instances
this ranges from 5° to 7° (Fig. 19.2). A long leg standing scanogram that
shows hip, knee and ankle anteroposterior (AP) view in one picture allows
measurement of the resection angle (Fig. 19.3).
Practical Tip
It is important to assess the rotation of the leg on scanogram before con-
sidering the angle of resection. Any external rotation of the leg will abnor-
mally indicate higher resection angle due to femoral bowing. This is easily
judged by assessing the position of patella on AP view.
Tibial resection is based on the long axis of tibia with the center of the
tibial plateau and the center of the ankle joint being the two reference points.
The center of the tibial plateau is fairly easy to localize and usually is the
point just medial to the lateral tibial eminence. The center of the ankle joint
is medial to the mid malleolar point as the lateral malleolus is more postero-
laterally placed. Most instrumentation systems have an ankle clamp that allows
adjustment mediolaterally. If the tibial resection is to be done with a posterior
slope as demanded by the implant design, it is important to set the rotation of
the jig aligned to the junction of central and medial third of the tibial tubercle.
Once the distal femoral resection and tibial resection are done per-
pendicular to the mechanical axis, extension gap balancing restores the
mechanical axis. So balancing and alignment have to be considered com-
plimentary to each other.
PRINCIPLES OF BALANCING
Normal knee has certain degree of laxity that is necessary to have free
motion. In terminal extension, there is no mediolateral laxity, and no dis-
Angle between the

mechanical axis and
anatomical axis
(5-7 degrees)
Anatomical axis
of femur
Mechanical axis
Distal femoral
resection Tibial resection
perpandicular to perpandicular to
mechanical axis long axis of tibia
Center of ankle joint
Fig. 19.2 Scheme of distal femoral and tibial resections to get mechanical alignment.
traction between medial or lateral

joint surfaces is possible. In this posi-
tion, posterior capsule along with
medial and lateral structures is tight.
At about 10° flexion and onwards,
posterior capsule is relaxed and only
medial and lateral structures pro-
vide mediolateral stability. Medially,
medial collateral ligament (MCL)
provides stability in both flexion
and extension, with posterior fibers
being tight in extension and anterior
fibers being tight in flexion. The lat-
eral stability is provided by multiple
structures and is a lot more dynamic
depending on the position of flex-
ion. The lateral collateral ligament
extends from lateral epicondyle,
which is a knuckle-shaped struc-
ture over lateral femoral condyle,
about 30 mm from the joint line. It
diverts away from the lateral femo-
ral condyle to insert in the fibular
head with no attachment to tibia.
The iliotibial tract provides lateral
stability only from full extension to
about 30° of flexion, beyond which
it ceases to provide stability laterally.
The popliteus is an important lateral
Fig. 19.3 Long leg scanogram.
stabilizer in flexion.
All deformities that are not correctable have a significant element of soft
tissue contracture, with tissues on the concave side of the deformity being
contracted and tissues on the convex side being stretched to varying degrees.
The Basic Rule of Balancing

Elongated structures cannot be contracted or restored to their original
length; therefore, the contracted or relatively contracted structures on the
contralateral side need to be released and elongated in a graduated manner
so as to match the elongated structures on the opposite side of the joint.
Technique of Balancing
The basic aim is to get both extension and flexion gaps rectangular, equal
and balanced. The distal femoral cut influences only the extension gap, the
posterior condylar cut influences only the flexion gap, while proximal tibial
cut influences both extension and flexion gaps. While distal femoral and
proximal tibial resections are done perpendicular to the mechanical axis,
extension gap balancing is done depending on the deformity and the tight
structures. The posterior condylar cuts can vary, both depending on the
femoral sizing and the rotation of the femoral component.
Most systems use anterior referencing for sizing whereby the anterior
level of resection remains constant and any downsizing leads to increase in
flexion gap. In systems that use posterior referencing for sizing, the anterior
cut changes with size, so downsizing can lead to notching of the anterior
cortex of femur.
Rotation of the femoral component largely influences the flexion gap
balancing. It is useful to distract the joint in flexion to assess the flexion
space, prior to posterior resection.
Balancing in Varus Knee

First step is to check whether the deformity is correctable. If the deformity
is fully correctable, no significant medial release is necessary and minimal
medial subperiosteal release is done to allow forward subluxation of tibia.
If the deformity is not correctable, a graduated medial release is necessary.
The initial medial dissection is subperiosteal and includes the release of
capsule on the posteromedial corner of tibia along with deep part of MCL.
Pes anserinus tendon insertions are generally not released and the superfi-
cial MCL insertion is released only over the proximal 3 cm of tibia at this
stage. The thickness of the proximal tibial resection needs to be reduced if
there is any stretching of lateral structures as indicated by the lateral com-
partment distraction on weight bearing AP X-ray. Once the extension gap
is created after the resection of distal femur and proximal tibial resection,
the balance is checked using rectangular spacer blocks. There should be 1
to 2 mm opening on both medial and lateral sides on the application of
varus and valgus stress. If at this stage, there is tightness on medial side, one
needs to employ following techniques that can achieve balancing without
having to release the superficial MCL completely.
1. Resection of medial femoral osteophytes: In most varus knees,
there is medial femoral osteophyte that tents the MCL and needs to be
excised. The medial edge of resected medial femoral condyle is traced

posteriorly and the osteophyte medial to it is resected with a straight
narrow osteotome without injuring the MCL attachment to medial
epicondyle (Fig. 19.4).
Fig. 19.4 Medial femoral osteophyte that is tenting the

medial collateral ligament (MCL) needs resection.
2. Size the femur and posterior capsular release: At this stage of

surgery, it is useful to know the femoral size, which essentially depends
on the AP dimensions of the distal femur. Most modular systems allow
size mismatch between the femoral and tibial components. By know-
ing the femoral size, one can determine the smallest tibial size that
will be compatible. At this stage, the joint is distracted in flexion to
judge the extent of tightness on the medial side. If there appears to
be significant tightness medially, one can increase the external rota-
tion of the femoral component from 3° to 5° based on the posterior
condylar line. At this stage, it is useful to resect only the posterior
condyles of femur without the anterior or the chamfer cuts, and the
jig is removed. If there is any preoperative flexion deformity, the pos-
terior capsule is released from the back of the femur with a curved
osteotome or electrocautery. It is useful to bend the tip of electro-
cautery and work anteriorly against the femoral cortex with knee in
acute flexion. The curved osteotome is used to protect the important
structures posteriorly.
3. Undersizing the tibia: Tibia is then sized, and the compatible smallest
size that will cover the lateral tibial plateau and be aligned to the junc-
tion of medial and middle one-third of the tibial tubercle is selected.

This normally leaves overhanging bone medially and posteromedially.
This overhang is resected flush with the medial edge of the tibial com-
ponent. This technique is called ‘reduction osteotomy’ (Fig. 19.5).
Fig. 19.5 Tibial downsizing and lateralization allow excision

of medial and posterior excess bone. This in turn helps with
medial balancing.
4. MCL piecrusting: If despite above two steps, medial side is still tight, care-
ful MCL piecrusting can stretch the medial side by another 2–3 mm. With
joint distracted, multiple punctures are made in the length of the MCL
using 18-gauge needle mounted on a syringe (Fig. 19.6). The number of
punctures needs to be graduated, as excessive punctures can make the MCL
incompetent. The usual number of punctures ranges from 10 to 16.
Fig. 19.6 Medial collateral ligament (MCL) Fig. 19.7 Complete superficial medial col-
pie-crusting with 18-gauge needle. lateral ligament (MCL) release can be done
subperiostealy keeping pes tendons intact.
If the medial side remains tight despite all the above measures, which
can happen in severe fixed deformity, the superficial MCL needs to be com-
pletely released subperiosteally from the tibia to almost 10 cm from joint
line. This is best done with a sharp curved osteotome or periosteal elevator.
The pes tendon attachments can be kept intact (Fig 19.7). At the end of the
release, if the medial side is lax, constrained prosthesis has to be used.
Balancing in Valgus Knee

Since lateral side of knee has multiple structures providing stability, the val-
gus knee correction and balancing are considered more challenging. The
distal femoral and proximal tibial resections based on principles mentioned
earlier present an asymmetrical extension gap that is tight laterally. It is
useful to place a lamina spreader or a distractor with flat discs in the joint
and apply distraction force. With distractor in place, tight structures can be
palpated. There are a variety of sequences of soft tissue release described in
literature. We describe our sequence of soft tissue release here:
1. Pie-crusting of ilio-tibial band: A distractor is placed in the joint
to get lateral structures under tension. Using a 15 number knife blade,
multiple punctures are made in the distal 5 cm of IT band. The tight
bands can be palpated and pie crusted. The distractor is removed and
the balance checked. If not balanced yet, the distractor is reapplied and
posterolateral corner and lateral structures are palpated.
2. Posterolateral capsule: With distractor in place, posterolateral capsule
is carefully released using 15 number knife.
3. Lateral collateral ligament (LCL): If the lateral side is still tight, it is
possible to palpate the tight LCL in the posterolateral corner of the knee.
Using the 15 number knife, a couple of stab incisions are made in the
length of the LCL. This usually releases the tight lateral side adequately
as one can feel a snap, and balance is achieved. With these releases, the
lateral side is usually still not incompetent, and standard posterior stabi-
lized prosthesis can be used without additional constraints.
Balancing the Flexion Gap

In a nondeformed knee, not much soft tissue releases are necessary. Most
systems use extension gap first technique and the techniques described
above are used to get extension gap balancing. Flexion gap is determined
next and is largely influenced by the degree of external rotation of the
femoral component. Posterior condyles are commonly taken as refer-
ence points, but need careful attention to the ensuing flexion gap. Trans-
epicondylar axis (TEA) is considered a better landmark to judge femoral

component rotation and normally TEA is on average at about 3° externally
rotated to the posterior condylar line in a normal knee (range 2° to 11°).
In a deformed knee, especially valgus knee, the lateral femoral condyle is
worn and hypoplastic. In such a situation, if posterior condyles are taken as
a reference line, the femoral component will possibly be in internal rota-
tion, leading to patellar maltracking. It is, therefore, useful to mark the TEA
in valgus knee. In a varus knee, there may be some wear of the posterior
condyle medially. In such a knee, one can still take posterior condyles as
reference, as the femoral component will be in slightly more external rota-
tion. This in fact improves the patellar tracking.
SUMMARY
Alignment and balancing are the two most crucial aspects of TKA that
determine the long-term outcome. Restoration of normal alignment needs
careful clinical and radiological assessment before surgery to determine the
distal femoral resection angle and determination of the soft tissue releases
necessary for deformity correction and balancing.
REFERENCES
1. Ranawat CS, Padgett DE, Ohashi Y. Total knee arthroplasty for patients younger than
55 years. Clin Orthop Relat Res 1989;248:27–33.
2. Rand JA, Trounsdale RT, Ilstrup DM, et al. Factors affecting the durability of primary
total knee prostheses. J Bone Joint Surg Am 2003;85-A(2):259–65.
3. Scuderi GR, Insall JN, Windsor RE, et al. Survivorship of cemented knee replace-
ments. J Bone Joint Surg Br 1989;71(5):798–803.
4. Gioe TJ, Killeen KK, Grimm K, et al. Why are total knee replacements revised?
Analysis of early revision in a community knee implant registry. Clin Orthop Relat Res
2004;428:100–06.
5. Fehring TK, Odum S, Griffin WI, et al. Early failures in total knee arthroplasty. Clin
Orthop Relat Res 2001;392:315–18.
6. Sharkey PF, Hozack WJ, Rothman RH, et al. Insall Award paper. Why are total knee
arthroplasties failing today? Clin Orthop Relat Res 2002;404:7–13.
Chapter 20
Cementation Techniques in Total

Knee Arthroplasty
Justin Duke, Douglas A. Dennis
INTRODUCTION
Cemented total knee arthroplasty (TKA) is widely accepted as the gold stan-
dard fixation method for TKA.1,2 Despite numerous design variations of the
tibial and femoral components (full keels, multiple lugs, etc.), the goal is to
obtain rigid fixation to the corresponding bone. Numerous reports demon-
strate aseptic loosening rates of near 2% at intervals of greater than 10 year
follow-up duration with cement fixation.3–5 A properly executed cementa-
tion technique not only provides long-term stable fixation, but also serves as
a barrier to the ingress of debris particles into the cancellous bone that can
result in osteolysis.6 This chapter will focus on the ideal cementing technique
and conditions that will yield the best long-term survival and outcome.
BONE CEMENT COMPOSITION

Various types of bone cement are available which can differ in viscos-
ity, tensile and compressive strength, and time of polymerization. Various
chemicals are present in powder and liquid form (Table 20.1), which are
mixed together, resulting in an exothermic reaction and subsequent polym-
erization. Antibiotics may be added to the powder by the manufacturer
or surgeon to prevent or treat an active periprosthetic infection. Surgeon
addition of antibiotics can reduce cost and allow custom tailoring of the
Table 20.1: Chemical composition of a standard bone cementa
Powder: > 50% Polymethyl methacrylate

1-3% Benzoyl peroxide
10-15% Barium sulfate
Liquid: >50% Methyl methacrylate
< 1.5% N,N-Dimethyl-p-toluidine
aDepuy CMV 1 Bone Cement, Blackpool, England

Cementation Techniques in Total Knee Arthroplasty 241
spectrum of antibiotic coverage. For optimum therapeutic benefit, the cho-

sen antibiotic should be thermally stable to avoid loss of activity from the
exothermic reaction of the polymer and monomer (Table 20.2).7, 8
Table 20.2: Antibiotics added to bone cement8
Acceptable antibiotics Decreased antibiotic activity due to
the heat of polymerization
Amikacin Chloramphenicol
Amoxicillin Colistimethate
Ampicillin Tetracycline
Bacitracin Liquid gentamicin, clindamycin,
Cefamandole or any aqueous suspension
Cefazolin Rifampin
Cefuroxime
Cefuzanam
Cephalothin
Ciprofloxacin
Clindamycin (powder)
Colistin
Daptomycin
Erythromycin
Gentamicin (powder)
Lincomycin
Methicillin
Novobiocin
Oxacillin
Penicillin
Polymymyxin B
Streptomycin
Ticarcillin
Tobramycin
Vancomycin
OPERATIVE TECHNIQUE
There are several factors influencing the tensile and shear strength of
the bone–cement interface. These include the preparation of the bone
surface,9,10 method of cement preparation,11–13 application of the cement
to the bone14–18 and the depth of cement penetration.9,10,13,15,16,19 It is
important to understand that bone cement is not a glue, and does not
chemically bond with either implant or bone. It functions as a ‘grout’ that
forms an intimate sleeve between the implant and interdigitates into the
cancellous structure of the bone.11,20 Poor cementation techniques risk

premature implant loosening. Careless removal of excess cement results in
micro and macroscopic third body particles, which can entrap within the
joint articulation and cause catastrophic polyethylene wear.21 In contrast
to total hip arthroplasty, there is no definitive consensus on the preferred
method of TKA cementation, and wide variations in technique have been
utilized. The following section discusses the available published literature
and the authors’ favored method of cementing a TKA.
Bone Preparation
Smooth and precise bone resections are important as irregularities of the
bone surface will prevent a uniform cement mantle. Areas of sclerotic bone
limit interdigitation of cement with cancellous bone and should be perfo-
rated with a small drill bit to a depth of 3 mm to enhance cement interdigi-
tation (Fig. 20.1 ). This is most commonly required on the worn side of
the tibia and the lateral patellar facet. The authors prefer to use a tourniquet
at least for cementation and component insertion. This allows the surgeon
to achieve the driest possible bone surface and decreases the influence of
fluids, blood and fat from mixing with cement which has been shown to
decrease the cement strength.10 Additionally, high bleeding pressure can
inhibit cement penetration into trabecular bone. The use of pulsatile lavage
has been shown to facilitate improved debris removal from the interstices
of cancellous bone, resulting in reduced postoperative radiolucent lines and
improved survivorship22 as well as better depth of cement penetration.13,23,24
Once the blood, fat and marrow have been removed via pulsatile lavage,
it is imperative to dry the bone. A dry laparotomy sponge is placed down the
tibial canal and onto the surfaces to be cemented until the time of cement
A B
Fig. 20.1: Intraoperative photograph of a sclerotic lateral patellar facet perforated with
a small drill bit (A) to enhance cement penetration (B).
application. At this stage of washing and drying the bone, it is wise to inspect
the posterior capsule for any residual boney debris that requires removal.
Cement Preparation
Cement preparation occurs concurrently with bone preparation. The
surgeon must be aware of the mixing and working time of the chosen
cement as variations exist among the multiple chemical formulations
of bone cement. Additionally, an increased operating room temperature
can accelerate the speed of curing of the cement. Evidence supporting
superiority of one type of cement over another is lacking. Lutz et al.
demonstrated no difference in cement penetration or incidence of radio-
lucent lines in TKAs cemented with low-viscosity cement using a cement
gun compared with standard-viscosity cement applied via a pressurizing
syringe.25 The current technique for cement mixing involves mixing
under conditions of a vacuum. This technique reduces the volume of
noxious fumes in the operating theater and the pore size of the cement,
which increases its yield strength.26
Cement Application and Component Insertion

The goal of cement application to the bone is to create a uniform cement
mantle that interdigitates with the cancellous bone to assure long-term fixation.
Some controversy exists regarding the required depth of cement penetration.
Biomechanical studies suggest a depth of penetration of 3 mm is desired.27,28
Due to the exothermic reaction of cement polymerization, a mantle that is
excessively thick can lead to adverse thermal necrosis of the bone.29,30
The tibial component is initially cemented. Histologic evaluations of the
bone–cement interface typically demonstrate excellent interdigitation of
cement centrally but often poor penetration of cement peripherally due to
the lack of pressurization from escape of the cement peripherally. It is our
opinion that good penetration peripherally is paramount to create a barrier
to ingress of microparticulate debris and subsequent osteolysis. Therefore,
the authors’ preferred technique is to peripherally pressurize the tibia plateau
using a cement gun to ensure good peripheral interdigitation (Fig. 20.2).16,19
Additional controversy exists regarding the need to cement the stem
of tibial trays.14 Maloney and Clohisy evaluated 97 TKAs fixed with sur-
face cementation only and observed a 14.4% (11 of 97) loosening rate at
a 2–8 years’ follow-up duration.31 A comparative evaluation of compo-
nent migration of TKAs fixed with surface vs. complete cementing using
Fig. 20.2: Intraoperative photograph demonstrating pres-

sure injection of the periphery of the proximal tibia using
a cement gun.
radiostereometry demonstrated increased migration in the surface only
cemented group.32 For these reasons, the authors favor complete cemen-
tation with hand pressurization of the tibial canal before component
insertion. The tibial component is then carefully inserted, keeping the
plateau portion parallel to the resected tibia to ensure a uniform cement
mantle and firmly impacted with a component driver. The method of
removal of excess cement is critical to avoid creation of microparticulate
cement debris fragments, which can be left in the knee joint, embed
within the polyethylene bearing and accelerate wear. A sharp elevator
is used to cut the excessive cement at its junction with the component
and the excess is removed in large fragments (Fig. 20.3A and B). Scraping
away the cement with curettes is to be avoided as it typically creates
residual small cement fragments which can later serve as third body
wear particles. Lastly, a wet laparotomy sponge is used to wipe the tray
periphery to remove any attached cement not removed using the cutting
procedure described above.
A B
Fig. 20.3: Intraoperative photograph demonstrating cutting of the excess cement (A)
with a sharp elevator and removal as a large fragment (B).
The femoral component is then cemented using the same principles

used with tibial cementation. In addition to pressure injecting the bone,
cement is applied to the backside of the component to decrease fat intru-
sion into the prosthesis–cement interface.17 Cement penetration into the
posterior condyles is often not ideal and consideration of hand pressur-
ization of this region before component insertion is wise. Flexion of the
femoral component during insertion is common and not desirable, par-
ticularly in posterior stabilized TKA designs in which flexion can lead to
impingement of the top of the intercondylar box on the anterior aspect
of the tibial spine. Initial impaction on the top of the intercondylar box
to drive the component out of flexion can avoid this problem (Fig. 20.4).
The tibial polyethylene insert trial is then inserted and the knee is the
brought into full extension to further pressurize the cement as the patella
is prepared. As discussed previously, the lateral facet of the patella is often
sclerotic and perforation of sclerotic bone is wise (Fig. 20.1 ). Hand
pressurization of the lug holes and sclerotic bone is performed before
component insertion. A locking clamp is applied to the patella until the
cement is cured.
After all components have been implanted and cement is cured, the
knee is dislocated anteriorly, the posterior compartment inspected and
cleaned and any excess cement is removed from all components. The final
modular tibial polyethylene bearing is inserted. The knee is then reduced
and the wound copiously irrigated to remove any residual bone or cement
debris. A substantial amount of nonvisible debris is often generated during
Fig. 20.4: Intraoperative photograph demonstrating femo-

ral component impaction applied via the top of the inter-
condylar box to avoid flexion of the component.
a TKA. It has been shown that irrigating with 5L of pulsatile lavage (3 L

before and 2 L after component insertion) was effective at removing 95%
of debris.21
SUMMARY
Use of cement fixation for primary TKA demonstrates excellent long-term
fixation. Meticulous cementation technique is important to optimize clini-
cal outcomes.
REFERENCES
1. American Joint Replacement Registry. Available at: www.teamwork.aaos.org/ajrr/. Fall
2013 Update.
2. National Joint Registry for England, Wales, and Northern Ireland. Available at: http://
www.njrcentre.org.uk/. 10th Annual Report, 2013.
3. Dixon MC, Brown RR, Parsch D, Scott RD. Modular fixed-bearing total knee
arthroplasty with retention of the posterior cruciate ligament. a study of patients fol-
lowed for a minimum of fifteen years. J Bone Joint Surg Am 2005;87(3):598–603.
4. Font-Rodriguez DE, Scuderi GR, Insall JN. Survivorship of cemented total knee
arthroplasty. Clin Orthop Relat Res 1997;345:79–86.
5. Rasquinha VJ, Ranawat CS, Cervieri CL, Rodriguez JA. The press-fit condylar
modular total knee system with a posterior cruciate-substituting design. A concise
follow-up of a previous report. J Bone Joint Surg Am 2006;88(5):1006–10.
6. Engh GA, Parks NL, Ammeen DJ. Tibial osteolysis in cementless total knee arthroplasty.
A review of 25 cases treated with and without tibial component revision. Clin Orthop
Relat Res 1994;309:33–43.
7. Arora M, Chan EK, Gupta S, Diwan AD. Polymethylmethacrylate bone cements and
additives: a review of the literature. World J Orthop 2013;18;4(2):67–74.
8. Joseph TN, Chen AL, Di Cesare PE. Use of antibiotic-impregnated cement in total
joint arthroplasty. J Am Acad Orthop Surg 2003;11:38–47.
9. Dorr L, Lindberg JP, Claude-Faugere M, Malluche HH. Factors influencing intrusion
of methylmethacrylate into human tibiae. Clin Orthop Relat Res 1984;183:147–52.
10. Krause R, Krug W, Miller J. Strength of cement–bone interface. Clin Orthop Relat Res
1982;163: 290–99.
11. Cooke FW, Cipolletti GB, Lunceford EM, Sauer BW. The Influence of Surgical Technique
on the Strength of Cement Fixation. Dallas, Texas: ORS, 1978.
12. Lindberg J, Dorr L, Malluche H. Cement Fixation of the Total Condylar Tibial Component.
New Orleans, LA: ORS, 1982.
13. Majkowski RS, Miles AW, Bannister GC, Perkins J, Taylor GJ. Bone surface preparation
cemented joint replacement. J Bone Joint Surg Br 1993;75:459–63.
14. Galasso O, Jenny JY, Saragaglia D, Miehlke RK. Full versus surface tibial baseplate
cementation in total knee arthroplasty. Orthopedics 2013;36:e151–e158.
15. Halawa M, Lee AJ, Ling RS,Vangala SS. The shear strength of trabecular bone from the
femur, and some factors affecting the shear strength of the bone cement interface. Arch
Orthop Trauma Surg 1978;92:19–30.
16. Mann KA, Ayers DC, Werner FW, Nicoletta RJ, Fortino MD. Tensile strength of the
cement-bone interface depends on the amount of bone interdigitated with PMMA
cement. J Biomech 1997;30: 339–46.
17. Vainbroukx M, Labey L, Innocenti B, Bellemans J. Cementing the femoral component
in total knee arhtroplasty: which technique is the best? The Knee 2009;16:265–68.
18. Vertullo CJ, Davey JR. The effect of a tibial baseplate undersurface peripheral lip on
cement penetration in total knee arthroplasty. J Arthroplasty 2001;16:487–92.
19. Macdonald W, Swarts E, Beaver R. Penetration and shear strength of cement–bone
interfaces in vivo. Clin Orthop Relat Res 1993;286:283–88.
20. Kusleika R Stupp SI. Mechanical strength of poly(methyl methacrylate) cement-human
bone interfaces. J Biomed Mater Res 1983;17: 441–58.
21. Helmers S, Sharkey PF, McGuigan FX. Efficacy of irrigation for removal of particulate
debris after cemented total knee arthroplasty. J Arthroplasty 1999;14:549–52.
22. Ritter MA, Herbst SA, Keating EM, Faris PM. Radiolucency at the bone–cement
interface in total knee replacement. The effects of bone-surface preparation and cement
technique. J Bone Joint Surg Am 1994;76:60–5.
23. Maistrelli GL, Antonelli L, Fornasier V, Mahomed. Cement penetration with pulsed
lavage versus syringe irrigation in total knee arthroplasty. Clin Orthop Relat Res
1995;312:261–65.
24. Norton M, Eyres K. Irrigation and suction technique to ensure reliable cement penetra-
tion for total knee arthroplasty. J Arthroplasty 2000;15:468–74.
25. Lutz MJ, Pincus PF, Whitehouse SL, Halliday BR. The effect of cement gun and
cement syringe use on the tibial cement mantle in total knee arthroplasty. J Arthroplasty
2009;24:461–67.
26. Macaulay W, DiGiovanni C, Restrepo A, Saleh K, Walsh H, Crossett L, Peterson M, Li
S, Salvati E. Differences in bone–cement porosity by vacuum mixing, centrifugation,
and hand mixing. J Arthroplasty 2002;17:569–75.
27. Bert JM, McShane M. Is it necessary to cement the tibial stem in cemented total knee
arthroplasty? Clin Orthop Relat Res 1998;356:73–8.
28. Peters CL, Craig MA, Mohr RA, Bachus KN. Tibial component fixation with cement:
full-versus surface-cementation techniques. Clin Orthop Relat Res 2003;409:158–68.
29. Banwart JC, McQueen DA, Friis EA, Graber CD. Negative pressure intrusion technique
for total knee arthroplasty. J Arthroplasty 2000;15:360–67.
30. Dipiso JA, Sih GS, Berman AT. The temperature problems in total hip replacements.
Clin Orthop 1976;121:95–8.
31. Maloney WJ, Clohisy J. Premature Failure of Surface Cementation Technique in
Primary Total Knee Arthroplasty. Proceedings of the Annual Meeting of the American
Academy of Orthopedic Surgeons; Paper 65, 2002, p. 624.
32. Saari T, Li MG, Wood D, Nivbrant B. Comparison of cementing techniques of the tibial
component in total knee replacement. Int Orthop 2009;33:1239–42.
Chapter 21
Patellar Resurfacing in Total Knee

Arthroplasty
Brian K. Daines, Douglas A. Dennis
INTRODUCTION
Total knee replacement (TKA) surgery is a predictable and successful sur-
gical intervention for end-stage arthritis. Controversy remains whether
to resurface or not to resurface the patella. Arguments for not resurfacing
the patellar include fewer complications, more physiologic patellofemo-
ral kinematics and superior remaining bone stock, should revision of the
patellar component be required.1–5 The rationale for patellar resurfacing
includes less anterior knee pain, higher patient satisfaction and lower revi-
sion rates.1, 3–12 With precise surgical technique and good prosthetic design,
complication rates in patellar resurfacing should be low. This chapter will
explore the literature regarding patellar resurfacing and provide our ratio-
nale and surgical technique for advocating patellar resurfacing.
LITERATURE REVIEW
The current literature is inconclusive regarding whether or not to resurface
the patella, as both options have supporting data. Thorough analysis of the
literature is limited because of the variable length of follow-up duration,
with many of the comparative analyses demonstrating short-term follow-
up.6,7 Also, the status of the patellofemoral joint at the time of TKA is
poorly documented. Within these limitations, it appears that short-term
comparative data is similar.
The Swedish Knee Arthroplasty Registry (1998–2007) demonstrated
that nonresurfaced patellar total knee arthroplasty (TKA) subjects had a 1.23
times higher risk of revision vs. subjects with a patellar resurfacing.13 The
Australian Orthopaedic Association National Joint Replacement Registry
demonstrated that the risk of revision is 1.32 times higher if the patella is
not resurfaced (p < 0.001).14 They showed that the risk is 1.52 higher in
posterior stabilized TKAs. Several recent meta-analyses of TKA with patellae
resurfaced vs. nonresurfaced demonstrate a higher incidence of anterior knee

pain patients who did not have the patella resurfaced.11,12,15
Studies supporting resurfacing the patella show increased anterior knee
pain in subjects without patella resurfacing.1–4 They also demonstrate that
secondary patellar resurfacing results are inferior to primary resurfacing.1,10
In studies evaluating mixed (one knee resurfaced and one knee unresur-
faced) bilateral TKAs, the resurfaced side is favored over the nonresurfaced
side.3,8,16 The literature supports resurfacing in rheumatoid arthritis,9,17
which suggests that nonresurfaced patellae may deteriorate clinically over
time,4,7,18 and notes that reoperation rates are higher if the patella is not
resurfaced.6,11,12 There also appears to be poor correlation between cartilage
condition at the time of surgery and postoperative patellofemoral pain and
function.19 Meticulous surgical technique is critical, however, to achieve
satisfactory results with patellar resurfacing.
SURGICAL TECHNIQUE
Due to the reasoning discussed above, it is the authors’ practice to resurface
the patella in all TKAs if possible. Cases in which the patella is not resurfaced
include patients with insufficient bone stock to gain adequate fixation and
those with severe patellar baja. In both of these clinical situations, we favor
performing a patellar arthroplasty in which the articular surface is removed
and smoothed, leaving a patellar thickness of approximately 12 mm.
Excellent clinical results can be obtained if a precise operative technique
is used. Sophisticated cuttings jigs are widely used for femoral and tibial
resections. However, the traditional technique of everting the patella and
performing a free-hand resection often leads to error. Operative goals of
patellofemoral resurfacing include an accurate patellar resection, mainte-
nance of patellar vascularity, proper positioning of components, avoidance
of soft tissue impingement and assurance of central patellar tracking.20 The
authors typically resect the patella after the femoral and tibial resections
have been completed to avoid retractor damage (compression) from pres-
sure applied to osteopenic patellar cancellous bone exposed after patellar
resection. If patellar subluxation is difficult due to extensor mechanism
tightness, the patella can be resected first to loosen the extensor mechanism
and facilitate surgical exposure. Large hypertrophic patellar osteophytes are
also debrided before any bone resections are performed to facilitate patellar
subluxation and exposure of the femur and tibia. Resection of the patella
can be successfully accomplished using a freehand method or with use of
a patellar resection guide as long as the following principles are followed.

Patellar resection must result in a symmetric patellar remnant with equal
medial and lateral facet thicknesses. Since the patella is asymmetric in shape
(medial thicker than lateral), this requires resection of more bone medi-
ally than laterally (Fig. 21.1A and B ). Typically, the resection proceeds
through the subchondral bone of the lateral facet with minimal lateral facet
removal. Asymmetric patellar facet thicknesses (medial versus lateral) fol-
lowing articular surface resection must be avoided as it increases the risk of
patellofemoral instability and patellar fracture.
A B
Fig. 21.1 (A) Intraoperative photograph of a patellar resection guide applied to the
patella demonstrating the plan to remove more medial than lateral (hemostat) facet.
(B) Intraoperative photograph of the resected patellar article surface demonstrating
minimal lateral facet resection through the subchondral bone to assure residual facet
thickness symmetry.
It is important to duplicate native patellar thickness, which requires

measurement of native patellar thickness before resection. The surgeon
must be aware of the exact thickness of the chosen patellar component.
The articular surface thickness removed should equate with the thickness
of the implanted component to duplicate patellar thickness. The quadri-
ceps and infrapatellar tendons are excellent anatomic landmarks for patellar
resection and restoration of patellar height.21 ‘Overstuffing’ of the patel-
lofemoral joint is thought to result in poor biomechanics of the extensor
mechanism, often leading to decreased range of motion and anterior knee
pain. This can result from a number of factors including over-sizing or
anterior translation of the femoral component, distal joint line position,
or increasing the patellar thickness.21 Any factor that excessively increases
the tension in the patellar retinaculum may lead to pain, decreased range
of motion and poor function. An excessive patellar resection results in
increased patellar strain and an increased fracture risk.22
Efforts to preserve vascularity include maintaining the fat pad,23,24 preser-

vation of the superolateral genicular artery during a lateral retinacular release
procedure25–27 and avoidance of patellar components with large central
anchoring holes, which cause a greater reduction in the intraosseous blood
supply than with use of components with smaller peripheral lugs.25,27,28
All three TKA components
require accurate positioning. Medial
shift and internal rotation of both
femoral and tibial components, as
well as lateral positioning of the
patellar component, must be avoid-
ed to prevent patellar maltracking.
Medialization of the patellar com-
ponent and utilization of patellar Fig. 21.2 Photograph of a patellar compo-
components in which the apex of the nent with the apex medialized 3 mm to
component is medialized (Fig. 21.2) facilitate central patellar tracking.
facilitate central patellar tracking. Patellar component medialization can
result in the uncoverage of the lateral facet and lateral facet pain postop-
eratively. The authors routinely resect any uncovered lateral patellar facet
to avoid this problem (Fig. 21.3A and B). Following tourniquet release,
central patellar tracking must be obtained using the no-thumb technique.
If patellar subluxation is initially present, realignment procedures are per-
formed until a balanced extensor mechanism is obtained.29,30 The indica-
tions for lateral retinacular release are influenced by the ‘no thumbs’ and
‘towel clip’ tests. Surgical goals should include centralizing the patellar
tracking throughout the range of motion. The role of the vastus medialis
obliquus muscle is simulated by the towel clip test and can influence the
A B
Fig. 21.3 Intraoperative photographs demonstrating exposed lateral patella that will not
be covered by the patellar component (A) which is removed with a rongeur (B) before
component implantation to avoid lateral facet pain.
postoperative presence of patellar tilt and subluxation, dislocation and the

rate of lateral release.31
Due to premature failure of many metal-backed patellar component
designs,32–35 use of cementless patellar components has become infrequent.
Excellent long-term fixation with cemented patellar components can be
expected23,36 if good fixation techniques are utilized. Since the articular
surface resection often extends through the subchondral bone of the lateral
facet, cement penetration into this region can be compromised. It is wise to
perforate any sclerotic subchondral bone numerous times to enhance cement
penetration (Fig. 21.4A and B) and hand-pressurize the component lug holes.
A B
Fig. 21.4 Intraoperative photographs demonstrating drilling of the sclerotic bone of the
lateral facet (A) to enhance interdigitation of bone cement (B).
Lastly, it is important to avoid patellofemoral soft tissue impingement.

This most commonly involves the fat pad or fibrosynovial proliferation
surrounding the patellar component. The senior author routinely debulks
the fat pad, leaving one centimeter of fat pad covering the patellar tendon
to facilitate tendon gliding. At completion of the procedure, any prolifera-
tive fibrosynovial tissue on the posterior aspect of the quadriceps tendon is
debrided to lessen the incidence of postoperative patellar crepitus (Fig. 21.5).
SUMMARY
Satisfactory results have been reported for both patellar resurfacing and
nonresurfacing in TKA. Recent randomized studies suggest reoperation
rates to convert nonresurfaced patellae to resurfaced patellae exceed reop-
eration rates from complications associated with primary patellar resurfac-
ing. The incidence of patellofemoral pain and reoperation rates are greater
in subjects in which the patella is not resurfaced. Long-term studies suggest
Fig. 21.5 Intraoperative photograph demonstrating

debridement of proliferative fibrosynovial tissue (arrow)
on the posterior aspect of the distal quadriceps tendon to
lessen the incidence of postoperative patellar crepitus.
that results of nonresurfaced patellae deteriorate over time both clinically

and radiographically. One should expect minimal complications and satis-
factory long-term function with use of a meticulous patellofemoral resur-
facing surgical technique.
REFERENCES
1. Boyd AD, Jr, Ewald FC, Thomas WH, Poss R, Sledge CB. Long-term complications
after total knee arthroplasty with or without resurfacing of the patella. J Bone Joint Surg
Am 1993;75(5):674–81.
2. Khatod M, Codsi M, Bierbaum B. Results of resurfacing a native patella in patients with
a painful total knee arthroplasty. J Knee Surg 2004;17(3):151–55.
3. Levitsky KA, Harris WJ, McManus J, Scott RD. Total knee arthroplasty without patellar
resurfacing. Clinical outcomes and long-term follow-up evaluation. Clin Orthop Relat
Res 1993(286):116–21.
4. Mayman D, Bourne RB, Rorabeck CH, Vaz M, Kramer J. Resurfacing versus not
resurfacing the patella in total knee arthroplasty: 8- to 10-year results. J Arthroplasty
2003;18(5):541–45.
5. Soudry M, Mestriner LA, Binazzi R, Insall JN. Total knee arthroplasty without patellar
resurfacing. Clin Orthop Relat Res 1986(205):166–70.
6. Badhe N, Dewnany G, Livesley PJ. Should the patella be replaced in total knee replace-
ment? Int Orthop 2001;25(2):97–9.
7. Bourne RB, Rorabeck CH, Vaz M, Kramer J, Hardie R, Robertson D. Resurfacing
versus not resurfacing the patella during total knee replacement. Clin Orthop Relat Res
1995(321):156–61.
8. Enis JE, Gardner R, Robledo MA, Latta L, Smith R. Comparison of patellar resurfac-
ing versus nonresurfacing in bilateral total knee arthroplasty. Clin Orthop Relat Res
1990(260):38–42.
9. Kajino A,Yoshino S, Kameyama S, Kohda M, Nagashima S. Comparison of the results of

bilateral total knee arthroplasty with and without patellar replacement for rheumatoid
arthritis. A follow-up note. J Bone Joint Surg Am 1997;79(4):570–74.
10. Karnezis IA, Vossinakis IC, Rex C, Fragkiadakis EG, Newman JH. Secondary patel-
lar resurfacing in total knee arthroplasty: results of multivariate analysis in two case-
matched groups. J Arthroplasty 2003;18(8):993–98.
11. Nizard RS, Biau D, Porcher R, et al. A meta-analysis of patellar replacement in total
knee arthroplasty. Clin Orthop Relat Res 2005(432):196–203.
12. Parvizi J, Rapuri VR, Saleh KJ, Kuskowski MA, Sharkey PF, Mont MA. Failure to
resurface the patella during total knee arthroplasty may result in more knee pain and
secondary surgery. Clin Orthop Relat Res 2005;438:191–96.
13. Knutson K, Robertsson O. The Swedish Knee Arthroplasty Register (www.knee.se).
Acta Orthop 2010;81(1):5–7.
14. Graves SE, Davidson D, Ingerson L, et al. The Australian Orthopaedic Association
National Joint Replacement Registry. Med J Aust 2004;180(5 Suppl):S31–4.
15. Pakos EE, Ntzani EE, Trikalinos TA. Patellar resurfacing in total knee arthroplasty. A
meta-analysis. J Bone Joint Surg Am 2005;87(7):1438-–45.
16. Waters TS, Bentley G. Patellar resurfacing in total knee arthroplasty. A prospective, ran-
domized study. J Bone Joint Surg Am 2003;85-A(2):212–17.
17. Picetti GD, 3rd, McGann WA, Welch RB. The patellofemoral joint after total knee
arthroplasty without patellar resurfacing. J Bone Joint Surg Am 1990;72(9):1379–82.
18. Shih HN, Shih LY, Wong YC, Hsu RW. Long-term changes of the nonresurfaced patella
after total knee arthroplasty. J Bone Joint Surg Am 2004;86-A(5):935–39.
19. Han I, Chang CB, Lee S, Lee MC, Seong SC, Kim TK. Correlation of the condition of
the patellar articular cartilage and patellofemoral symptoms and function in osteoarthritic
patients undergoing total knee arthroplasty. J Bone Joint Surg Br 2005;87(8):1081–84.
20. Dennis DA. Extensor mechanism problems in total knee arthroplasty. Instr Course Lect
1997;46:171–80.
21. Briard JL, Hungerford DS. Patellofemoral instability in total knee arthroplasty. J Arthroplasty
1989;4(Suppl):S87–97.
22. Reuben JD, McDonald CL, Woodard PL, Hennington LJ. Effect of patella thickness on
patella strain following total knee arthroplasty. J Arthroplasty 1991;6(3):251–58.
23. Ranawat CS. The patellofemoral joint in total condylar knee arthroplasty. Pros and cons
based on five- to ten-year follow-up observations. Clin Orthop Relat Res 1986(205):93–9.
24. Dorr LD, Boiardo RA. Technical considerations in total knee arthroplasty. Clin Orthop
Relat Res 1986(205):5–11.
25. Clayton ML, Thirupathi R. Patellar complications after total condylar arthroplasty. Clin
Orthop Relat Res 1982(170):152–55.
26. Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following
total knee arthroplasty. J Arthroplasty 1987;2(2):135–40.
27. Dennis DA, Clayton ML, O'Donnell S, Mack RP, Stringer EA. Posterior cruciate con-
dylar total knee arthroplasty. Average 11-year follow-up evaluation. Clin Orthop Relat
Res 1992(281):168–76.
28. Scott RD, Turoff N, Ewald FC. Stress fracture of the patella following duopatellar total
knee arthroplasty with patellar resurfacing. Clin Orthop Relat Res 1982(170):147–51.
29. Merkow RL, Soudry M, Insall JN. Patellar dislocation following total knee replacement.
30. Scott RD. Prosthetic replacement of the patellofemoral joint. Orthop Clin North Am
1979;10(1):129–37.
31. Archibeck MJ, Camarata D, Trauger J, Allman J, White RE, Jr. Indications for lateral
retinacular release in total knee replacement. Clin Orthop Relat Res 2003(414):157–61.
32. Leblanc JM. Patellar complications in total knee arthroplasty. A literature review. Orthop
Rev 1989;18(3):296–304.
33. Bayley JC, Scott RD. Further observations on metal-backed patellar component failure.
Clin Orthop Relat Res 1988(236):82–7.
34. Bayley JC, Scott RD, Ewald FC, Holmes GB, Jr. Failure of the metal-backed patellar
component after total knee replacement. J Bone Joint Surg Am 1988;70(5):668–74.
35. Brick GW, Scott RD. The patellofemoral component of total knee arthroplasty. Clin
Orthop Relat Res 1988(231):163–78.
36. Doolittle KH, 2nd, Turner RH. Patellofemoral problems following total knee arthro-
plasty. Orthop Rev 1988;17(7):696–702.
Chapter 22
Unicondylar Knee Arthroplasty

Ashok Rajgopal, Himanshu Gupta, Attique Vasdev
HISTORY
The concept of unicondylar replacement of only one compartment of the
knee joint came from Duncan Mc Keever in the 1950s, followed up by
both Mc Keever and MacIntosh1 who introduced metallic tibial compo-
nents that resurfaced only the tibial plateau. These were associated with
high complication rates and unacceptable functioning.
John Charnley developed a convex ultra-high-molecular weight poly-
ethylene (UHMWPE) femoral component to articulate against a flat metal-
lic plateau, which did not have a prolonged life due to loosening, deforma-
tion and wear of the plastic femoral component.2,3
Following this, in 1972, Dr Leonard Marmor4 developed a prosthetic
design and showed good results in his series.
PRINCIPLE
Unicondylar knee arthroplasty in the real sense is resurfacing only one
compartment of the knee joint. One tibiofemoral component is resurfaced
in order to reduce deterioration of the joint space and to eliminate resul-
tant pathological joint biomechanics.5–7 A unicondylar replacement cannot
change the natural alignment or ligamentous balance of the knee. Slight
undercorrection of the deformity with insertion of an adequate thickness
of polyethylene is an important contributor to a successful outcome.8 For
patients presenting with a degenerative disease involving only one compart-
ment, the options usually are limited to arthroscopic debridement, osteotomy
and changing the joint alignment and weight bearing forces or going in for a
unicompartmental knee arthroplasty (UKA). Of all these options, UKA has
shown to have better results compared to the other two in medium to long
term. Repicci concluded that UKA minimizes physiological damage, has
minimal interference with lifestyle and avoids any interference with future
treatment options.9 UKA addresses single compartment disease and preserves
bone and soft tissue.10
INDICATIONS
It has been proven in many studies that improper patient selection is
thought to be a risk factor for early UKA failure. Classic indications
described by Kozinn and Scott and others include11–15:
1. a patient with a sedentary occupation;
2. age 60 years and older;
3. minimal rest pain;
4. varus or valgus malalignment of less than 10º;
5. range of motion of at least 90º with no flexion contracture;
6. correctable medial deformity;
7. weight less than 82 kg;
8. intact ACL with a stable knee that resists femorotibial subluxation and
normal articular cartilage in the opposite compartment;16 and
9. diagnosis of osteoarthritis, post-traumatic arthritis or osteonecrosis.
Some indications that have been recently updated have been to include
patients with monocompartmental arthritis in patients less than 60 and those
with BMI less than 30 as medications for unicompartment replacement.
Contraindications for UKA, traditionally, have been a diagnosis of rheu-
matoid arthritis or other inflammatory arthritis, knee pain including all
compartments, decreased range of motion with a flexion deformity, knee
instability, anterior cruciate ligament (ACL) rupture and obesity.5,12,17
All these have been identified as factors associated with unfavorable results.
Preop planning includes some specific radiographs, which are essential
in deciding whether the patient is an ideal candidate and also in the plan-
ning of surgery:
AP views with To look for mechanical

standing (Fig. 22.1A) alignment and to assess the
in full extension : damage in the involved and
uninvolved compartments.
in 40º flexion: To assess the status of the
posterior condyles.
Lateral view (Fig. 22.1B): To determine the area of
degeneration in the sagittal plane.
Posterior degeneration
indicates ACL insufficiency.
Skyline view: For assessing degeneration in the
patellofemoral joint.
Unicondylar Knee Arthroplasty 259
A B
Fig 22.1 Medial compartment degenerative arthritis. (A) Anteroposterior (AP) radio-
graph. (B) Lateral radiograph.
The surgical principles in UKA surgery are stringent patient selection

criteria, careful surgical technique and a proven prosthetic design. The
components are placed in such a way that the tibial and femoral compo-
nents are in maximum congruency in both flexion and extension. There
are various different types of UKA available such as a fixed and a rotating
platform UKA. We have not used a rotating platform UKA as we have
experienced good results with fixed platform UKA. Also many surgeons
across the world are doing bicondylar UKA as a norm in both condylar
involvement, but we would recommend a TKA in such cases owing to the
associated patellofemoral involvement in almost all cases of varying degrees.
Surgical Technique
The patient is positioned on a routine operating table with the knee flexed
at 90° with the foot resting on the table after inflating the thigh tourniquet.
The length of the skin incision varies from 6 to 8 cm. The upper limit for
a medial UKA would be the medial pole of the patella, extending distally
towards the medial side of the tibial tuberosity.
For a medial UKA, a medial parapatellar arthrotomy is done, whereas
for a lateral UKA, a lateral capsular arthrotomy is performed. The anterior
and mid portions of the meniscus are removed at this step.
After exposure, ACL strength is evaluated at 45º of knee flexion, and
intercondylar and medial osteophytes are removed. After the removal of

these peripheral osteophytes, there is a relative lengthening of the MCL,
allowing passive correction of the deformity.
Femoral Component
The femoral intramedullary canal is drilled after bringing the knee to a
lesser degree of flexion and then a femoral distal resection guide is posi-
tioned in the center of the mediolateral dimension of the femoral condyle.
After the completion of the cuts, posterior osteophytes are removed to
increase the range of flexion. The ideal anteroposterior (AP) size of the
femoral component should extend far enough anteriorly to cover the
weight bearing surface that comes in contact with the tibia in full exten-
sion, leaving 1–2 mm of exposed bone on the cut surface, at the junction
with the trochlear groove.
Tibial Component
After having completed the femoral cuts, the tibial jig is placed using
the extramedullary technique. The jig is placed distally around the
ankle joint with the axis of the guide lying slightly medial to the center
of the ankle joint. The proximal part of the guide is translated on the
anterior affected tibia. The diaphyseal part is parallel to the anterior
tibial crest, and AP positioning is done to reproduce the natural poste-
rior slope of 5°. The amount of resection is usually between 6 and 8
mm, reproducing in the horizontal plane the height of the unaffected
lateral condyle. The sagittal cut is done freehand close to the tibial
spine’s eminence, without violating the ACL tibial footprint. The ideal
size for the tibial component is one that provides the best mediolateral
coverage without overhanging medially.
Alignment
Before the final preparation of the tibia, spacer blocks are used to check
the balance in both the flexion and extension. After putting in the trial
implant, a 1–2 mm opening of the joint space applying a valgus stress is
looked for to avoid any overcorrection.
The final implants are cemented in place taking care to remove any
extra cement.
These should be placed in the center of the compartment to avoid weak
fixation or early loosening due to offset placement (Fig. 22.2A and B).
Most failures reported with UKA surgery have been attributed to technical
error (Figs 22.3–22.5).
A B
Fig. 22.2 Postoperative radiograph showing medial unicompartmental knee arthro-
plasty (UKA). (A) Anteroposterior (AP) view. (B) Lateral view.
Fig. 22.3 Femoral component loosening. Fig. 22.4 Wrong placement of femoral
component.
Fig. 22.5 Subsidence of tibial component.
POST OP REHABILITATION
Before the final closure of the capsule, a drain is inserted as this avoids
haematoma formation and thus decreases post op pain in return. We use
low molecular weight heparin from first postoperative day onwards for a
total of 10 days, which is combined with pulsatile compression stockings
to minimize the chance of post op deep vein thrombosis (DVT). Quadriceps
setting exercises and attempts at straight leg raising are initiated as toler-
ated and are achieved on postoperative Day 1 or 2. Knee flexion using
a continuous passive motion machine is initiated from Day 0 itself. The
patient commences walking from the next day after surgery, and in most
cases, walks within 1 week with a cane and discontinues the use of cane
at 2–3 weeks post op.
RESULTS
Early results of UKA were discouraging, but with recent evolution
in patient selection, implant design and surgical techniques have led
to much improved results in the last two decades.18–20 In patients of
medial UKA, the best results have been obtained when the postoperative
mechanical axis is in the center or
slightly medial to the knee center.
Over correction (Fig. 22.6) as well
as severe undercorrection have been
associated with early failures.21
In 1976, Marmor22,23 reported
on 105 patients with a minimum of
2 years of follow up, and he achieved
successful results with functional
improvement and a stable articula-
tion in 88% patients. After 10–13
years, patients implanted with the
Marmor knee maintained satisfac-
tory results in 70% cases, and 86.6%
patients remained pain free.
In 1980, Insall and Aglietti24
reported their results on 32 UKAs.
They demonstrated a decrease in
Fig. 22.6 Over correction of deformity in the varus angulation from the pre
medial osteoarthritis knee. op period to the post op status and
had 55% satisfactory results compared to 45% poor results.
In 1986, Broughton et al.25 published their results on 42 UKAs and
reported to have 76% (32 knees) good results and at the end of 5–6 years
post surgery 57% (24 knees) did well.
Similar mid- to long-term results were obtained by Bert in 1998.5
He showed 87.4% survivorship of the UKA 10 years after the proce-
dure.
Scott et al.26 reported 85% survivorship at 10 years, with the end point
defined as revision arthroplasty.
Stockelman and Pohl27 reported 43 satisfactory results and four revi-
sions at an average of 7.4 years after 47 UKAs.
Christensen28 reported that 7 out of a total of 575 UKAs required
revision to a total knee arthroplasty at 2–11 years.
Murray et al.29 in a comprehensive large volume series showed out-

comes of 143 knees treated with a medial UKA using Oxford mobile
bearing prosthesis between 1982 and 1992. Patients were followed for a
mean duration of 7.6 years postoperatively and they reported 97% survi-
vorship. The five revisions they had reported were: two for progression
of degenerative disease; two for loosening; one for infection and one for
an unexplained pain without any radiographic abnormality.
Even functionally, UKAs have been found to be better than osteotomy
that patients undergo. Ivarsson and Gillquist30 reported that patients who
had UKA demonstrated better gait velocity and superior muscle strength
compared with those who had undergone an osteotomy.
When compared to a TKA, the various reasons in favor of a UKA are less
perioperative morbidity, reduced blood loss, shorter hospital stay, increased
postsurgical range of motion and reduced surgical costs.5,6,11,12,16,31 Many
studies have been done comparing the results of both these.
Laurencin et al.32 followed 23 patients who underwent a UKA in
one knee and a TKA on the contralateral side. These patients were
operated on both sides by the same surgical team, and received same
inpatient care and rehab protocol in both knees. At the follow up of
81 months, postoperative range of motion improved more in the UKA
side than the other.
Dalury et al.33 found that in 23 patients with UKA on one side and
TKA on the contralateral side, the UKA patients felt less pain and the
ranges were much better than those of the TKA.
Patil et al.34 also concluded that tibial axial rotation and femoral rollback
more closely resemble normal anatomy in UKA compared to a TKA.
The widespread use of UKA has been limited by the technical difficulty
in performing the procedure. It has been found in many studies that UKA
has less tolerance for unacceptable component positioning when compared
to TKA, as improper component positioning by as little as 2°, can result in a
failure.6,35–41 Other reasons for an early failure are medial–lateral mismatch,
heterogeneous polyethylene wear, inadequate stability of components,
improper patient selection, aseptic loosening (Figs 22.7 and 22.8) and tibial
subsidence.5,42
With precise selection in a patient with single compartment involve-
ment, UKA provides for better physiological function and quicker recov-
ery as compared to TKA, with a reliable surgical technique bone stock
is preserved and survivorship expected to exceed 90% at 10 years.43–45
Fig. 22.7 Wrong placement leading to Fig. 22.8 Wrong placement leading to
mismatch of femoral and tibial compo- mismatch of femoral and tibial compo-
nent – anteroposterior (AP) view. nent – lateral view.
Our Experience
Well, in our cases, we select the modality of treatment based on the scheme
shown in Table 22.1.
Table 22.1 Author-preferred modality of treatment in patients with unicompartmental
arthritis
Unicompartmental arthritis
Age < 40 years Age > 40 years Age > 40 years

Varus < 10°/Valgus Varus < 10°/Valgus Varus > 10°/Valgus
<10° <10° >10°
Full range of motion Correctable deformity Fixed deformity
No fixed deformities BMI < 26 BMI > 26
Full range of motion Restricted range
No fixed deformities of motion
High tibial osteotomy Unicondylar knee Total knee arthroplasty

arthroplasty
As the knowledge about the patient selection and surgical techniques

has evolved along with the prosthesis designs, even our results have shown
to improve sequentially. In the last 12 years, we have done 768 cases of
UKA with a mean follow up of 9.2 years and a mean age of 64 years. Of
these, we have had 19 failures or conversions to a total knee arthroplasty.
The various reasons we found in our series for failure were progression
of contralateral compartment arthritis in 11 knees, component loosening in
6 cases, infection in 1 case and a periprosthetic femoral fracture in 1 patient.
The infected case was dealt with a two stage revision arthroplasty.
CONCLUSIONS
The technical demands of performing UKA, coupled with a small mar-
gin for errors, have limited the widespread use of this surgical technique.
Though the results of UKA are in many cases even better than TKA, the
important criteria on which these are dependent are proper patient selec-
tion, use of a good prosthesis and a surgical procedure, which is technically
perfect for a long-lasting successful UKA.
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41. Whiteside LA. Making your next unicompartmental knee arthroplasty last: three keys
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Chapter 23
Technique: Fixed Bearing Total

Knee Arthroplasty
Hemant Wakankar
INTRODUCTION
Fixed bearing total knee arthroplasty (TKA) is historically the gold stand-
ard and a well-proven concept. Fixed bearing essentially refers to the tibial
component that is fixed to the bone either as a monoblock all poly tibial
component or a metal tibial tray in which the polyethylene component is
locked. The alternative that is becoming popular is the rotating platform in
which the tibial polyethylene component is free to rotate on the metal tray.
TKA evolved in 1974 with total condylar prosthesis, which originally
had an all polyethylene single piece tibial component.1,2 Later, the metal-
backed modular tibial component was introduced in the Insall-Burstein
(IB) prosthesis. The modularity allowed the surgeon to choose the poly
thickness even after the metal tibial tray was cemented in, and soon this
became widely popular.
The total condylar prosthesis required the sacrifice of the posterior
cruciate ligament (PCL) but did not have the mechanism to reproduce the
normal tibio-femoral rollback that occurs with flexion. As a result, the flex-
ion was restricted to about 95°. The femoral rollback refers to the tibio-
femoral contact point, which moves posteriorly on tibia with increasing
flexion in a normal knee and is a function of PCL. With the introduction
of cam and post mechanism in the articulation, the consistent rollback was
ensured3–5 and the range of movement improved. This is called posterior
stabilized (PS) TKA in which PCL is sacrificed. Alternatively, PCL can be
preserved in TKA and can be carefully balanced to reproduce the normal
rollback. This is called cruciate retaining (CR) TKA (Fig. 23.1).
Essentially, PS and CR total knee arthroplasty are two philosophies with
no proven superiority of one over the other.6,7 Both are types of fixed bear-
ing TKA. There are differences in the indications, patient selection and the
surgical technique of the two. PS TKA can be used universally in all cases,
while CR TKA is difficult in knee deformities exceeding 20° in any plane.
Fig. 23.1 Cruciate retaining (CR) and posterior stabilized

(PS) prosthesis. Note the intact posterior cruciate ligament
(PCL) with CR total knee arthroplasty (TKA).
POSTERIOR STABILIZED FIXED BEARING TOTAL KNEE

ARTHROPLASTY
The function of PCL is to provide proprioception and consistent femoral
rollback. As the knee advances into flexion, the checkrein effect of pos-
terior cruciate does not allow posterior shift of tibia on femur, and as a
result the contact point on tibia shifts posteriorly. The same kinematics
is reproduced in PS TKA in which the tibial articulating surface has a
peg in the center and the femoral component has a transverse cam that
articulates with the tibial peg.
Surgical Technique
The TKA essentially consists of three basic bone cuts:
1. Distal femoral cut
2. Proximal tibial cut
3. Posterior femoral cut
The aim of these three cuts is to achieve symmetrical, equal and bal-
anced gaps between the femur and tibia in full extension (extension gap)
and at 90° of flexion (flexion gap) (Fig. 23.2). All other femoral cuts are
necessary to accommodate the femoral component fit on the distal femur.
These cuts include anterior cut, anterior and posterior chamfer cuts and
the box cut for peg–cam mechanism.
Most common surgical technique establishes the extension gap first.
One may choose to resect distal femur first and tibia later or vice versa.
Other less popular technique establishes the flexion gap first, starting with
tibial resection followed by posterior femoral condyles. We describe here
our technique of extension gap first.
Technique: Fixed Bearing Total Knee Arthroplasty 271
Fig. 23.2 Balanced and equal flexion and extension gaps.
Approach
Skin is incised in midline with knee in flexion, starting about 2 inches
above upper pole of patella and distally to about just medial to the tibial
tubercle. The most common approach is the medial parapatellar approach
in which arthrotomy starts in the quadriceps tendon, leaving a small cuff
of tendon attached to vastus medialis. The arthrotomy is carried around
patella medially to just 2 mm medial to the edge of patellar tendon. The
medial tibia is exposed by subperiosteal dissection using sharp curved peri-
osteal dissector and the dissection is carried to the posteromedial corner of
tibia. Pes anserinus insertion is not violated. The anterior cruciate ligament
is cut and the tibia is subluxed forward.
Warning
During exposure, no dissection is done in the subcutaneous tissue as it can
compromise the vascularity of skin. The medial dissection is subfascial to
expose the musculotendinous junction of vastus medialis and virtually no
lateral dissection is necessary. The medial soft tissue flap from proximal tibia
needs to be carefully dissected and subperiosteally elevated so that it can
later be closed well to get watertight closure. If this flap gets shredded or is
poorly developed, good watertight closure is difficult.
It is important not to force the tibia to sublux forward. If with hyper-
flexion, the tibia does not sublux or if the knee is stiff, put the knee in
figure of four position and release the capsule and deep medial collateral
ligament (MCL) from the posteromedial tibial rim. If this is inadequate, use
a curved sharp osteotome to resect the posteromedial osteophyte without
damaging the MCL.
Distal Femoral Cut

The femoral entry point is marked
on the line joining the top of the
intercondylar notch and the bottom
of the trochlear groove (Whiteside’s
line), 1 cm anterior to the top inser-
tion of PCL (Fig. 23.3). The entry
hole is drilled and over-reamed to
accept the medullary canal rod of
the jig. It is useful to lavage the med-
ullary canal with long suction tube
to reduce incidence of fat embolism.
Most systems use intramedullary
reference jigs. The angle of resection Fig. 23.3 Entry point for femoral canal is on
is judged on the long leg scanogram Whiteside’s line 1 cm anterior to the pos-
done in neutral rotation, and is usu- terior cruciate ligament (PCL) attachment.
ally set at 5–7° to resect perpendicu-
lar to mechanical axis. It is impor-
tant to set the jig completely against
the distal surface of femur. In a varus
knee, the jig normally touches the
lateral femoral condyle with a small
gap medially (Fig. 23.4). Opposite is
true in a valgus knee.
The cutting block is fixed to the
anterior aspect of femur with mini- Fig. 23.4 Distal femoral resection angle is
mum 3 pins and the jig is taken off. set using intramedullary jig.
The distal femur is cut with oscillat-
ing saw to resect 9–10 mm of distal femur on the less worn side.
Warning
Most cutting slots are 1.27 mm wide and recommended saw blade thickness
is 1.2–1.25 mm. If a thinner saw blade is used, the resection thickness can
vary significantly leading to inaccuracy. The saw should be held firmly with
the flat surface of the saw blade kept flush with the distal face of cutting slot.
The saw blade should be allowed to move freely without jamming.
Proximal Tibial Cut

The tibia is subluxed forwards and a curved Hohmann spike with blunt
tip is passed behind tibia in front of

the PCL. This spike rests of the distal
femur and it is important to cushion
it with a surgical cotton sponge.
One Hohmann 15 mm wide spike
is passed laterally beyond the lateral
rim of tibial plateau and another
medially protecting the medial col-
lateral ligament (MCL) (Fig. 23.5).
Most systems use extramedul-
lary alignment jig with ankle clamp.
The jig is first placed around the
ankle and rotation of the jig is
aligned to the junction of medial Fig. 23.5 Proximal tibial resection. Note
and central third of the tibial tuber- the use of Hohmann spikes for protection.
cle. Proximally, the jig may have a spike that can be fixed to the center of
the tibial plateau. The cutting block of the tibia is pushed close to bone
and held there. The slope of the cut can vary depending on the prosthesis
used and can be 0–7°. Most systems have the slope marked on the cutting
block. The long arm of the jig is kept parallel to the shin of tibia. The ankle
position of the jig is set next. The center of the ankle joint is medial to the
mid-malleolar point and the position of the jig is set accordingly. Other
reference landmarks that can be used include tibialis anterior tendon and
the second metatarsal. However, in the presence of foot deformities or a
very mobile foot, these landmarks are unreliable.
After the tibial jig is locked in position, the slope of the cut is checked
using angel wing depth resection guage. The level of resection is then ref-
erenced on the less worn side using a stylus. In a non-deformed varus knee,
9–10 mm is resected using the lateral side as reference. The cutting block
is pinned in place and proximal tibia is resected. Resected proximal tibia is
excised and thickness is measured. The tibial jig is then removed.
Warning
It is important not to use extra long saw blade as it can go beyond the tibia
to injure vital structures. The four spikes are used to protect structures:
medially protecting medial collateral ligament (MCL), posteriorly pro-
tecting neurovascular bundle, two laterally protecting patella and patellar
tendon (Fig. 23.5).
The stumps of the anterior and posterior cruciate ligaments are excised.
Any bleeding points are coagulated. The knee is then placed in extension and
remaining medial meniscus is excised taking care not to damage the MCL.
Extension Gap
With knee in extension, extension
gap is first visually checked and bal-
ance is then checked with spacer
blocks. The joint is stressed medi-
olaterally and any opening on either
side is noted. Ideally, with block in
extension gap, the joint should open
on each side by 1–2 mm (Fig. 23.6).
Femoral Sizing
Anterior vs. posterior referencing
system: The femoral sizing is based
on the anteroposterior (AP) dimen-
sion of femur and not on mediolateral
dimension. The anterior and posteri-
or referencing refers to whether ante-
rior or the posterior cut remains con-
stant with up or downsizing. Majority
of systems are anterior referencing Fig. 23.6. Extension gap balance and
wherein anterior cut remains constant checking the alignment.
and with downsizing, more posterior resection is done, increasing the flexion
gap. In posterior referencing system, the posterior resection remains constant
and with downsizing, more anterior bone will be resected, which may cause
notching of anterior cortex. This is important in situation when the measured
size is in between two sizes and one has to choose the upper or the lower
size. Generally, in posterior referencing system, one should choose higher size
to avoid anterior notching. In anterior referencing system, one should choose
lower size so that flexion space is not too tight.
Effect of resection of PCL on flexion space: Normally, with resec-
tion of PCL, flexion space tends to increase by 2–4 mm. This should be
kept in mind before AP resection. If on visual inspection of flexed space,
the gap appears larger, one should choose one size higher for less posterior
resection (with anterior referencing). If needed, it is easily possible to go to
the lower size and resect more bone posteriorly.
Flexion Space and Femoral Preparation

The knee is then distracted in 90° flexion and the flexion space is visually
checked. If it appears too tight medially, more external rotation may be nec-
essary. The routine femoral anterior and posterior resection is in 3° of exter-
nal rotation with reference to the posterior condylar line and therefore more
thickness of posterior medial condyle is resected than the lateral side. The
femoral sizing jig is placed on distal femur, with posterior arms of the jig
resting on the posterior condyles. Anterolateral ridge of femur is the anterior
reference point for the sizing. Appropriate rotation is selected and reference
pins are placed. The AP cutting block is fixed to the distal femur and flexion
space is checked for the last time visually before resecting the anterior and
posterior condyles. The chamfer cuts and trochlear cuts, if demanded by the
system, are also done at this stage. The block is removed and resected bone
is taken off. The knee is placed in acute flexion and posterior osteophytes
are resected using a curved osteotome. Spacer block is then inserted in the
flexion space at 90° of flexion to check the balance and if it is equal to
the extension space. Slightly loose flexion space is acceptable but a flexion
space much tighter is likely to cause loss of flexion and one should consider
downsizing (in anterior referencing system) to get more flexion space.
Warning
It is important to protect medial collateral ligament (MCL) while resecting
posterior condyles using a 15 mm Hohmann retractor placed in the axilla
of MCL. It is important not to resect posterior condyles with uncontrolled
saw blade exit. It can cause serious injury to posterior structures (Fig. 23.7).
Intercondylar box cut: The

box cutting jig is fixed over the distal
femur and using a reciprocating saw,
the box cut is done. This concludes
the femoral preparation.
Tibial Preparation
The tibia is sized to accept the base-
plate that covers the lateral tibial
condyle completely. The rotation is
Fig. 23.7 Posterior condyle resection. set to align to junction of medial
Note the Hohmann spike protecting the third and lateral two-thirds of the
medial collateral ligament (MCL). tibial tubercle. Any excessive promi-
nent bone on posteromedial side is excised. The tibia is drilled to accept

stem as required and broached in correct rotational alignment.
Tibial and femoral sizing compatibility: Most systems allow some
size mismatch between tibial and femoral sides. However, it is important
to know what degree of incompatibility is allowed. In some severely
deformed varus knees, it is advisable to downsize and lateralize the tibial
component so that reduction osteotomy can be done on the medial tibial
flare. In such situation, it is useful to know the femoral size early in surgery,
so that the smallest compatible tibial size is known.
Patellar Resurfacing
If patellar articular surface is worn out and if the patella is at least 20 mm
thick, patellar resurfacing can be done. Using either a free hand technique
or a patellar clamp, 8–9 mm of articular side of patella is resected parallel to
the anterior surface of patella. The cut patellar surface is sized and prepared
to accept appropriate patellar button. With the trial patellar button in place,
the composite thickness is measured to make sure that there is no overstuff-
ing of patellofemoral joint.
Trial Reduction
The trial tibial, femoral and patellar components are inserted in place
and trial poly component is fitted. The knee is placed through range of
motion and the mediolateral stability is observed. In full extension with
posterior capsule being tight, there should not be any opening medi-
olaterally. However, the most important position to assess the stability is
about 5–10° of flexion when there should be about 1–2 mm opening on
either side. At 90° of flexion, the stability is checked by rocking the tibia
sideways. If knee appears lax in both flexion as well as extension, a thicker
poly insert is tried.
Patellar stability is checked through the range of motion without the
thumb on the patella. If at this stage, the patella tends to sublux laterally,
tibial rotation is checked. The lateral patellofemoral ligament is released
and any tight bands in the lateral retinaculum are palpated. If any such
bands are present, they are released. The lateral genicular artery may pass
within these bands and should be preserved if possible.
Things to Check on Trial Reduction

s Mediolateral stability in:
Full extension
90° flexion
5–10° flexion
s Residual flexion deformity
s Patellar tracking without thumb on the patella
s Tight lateral patellar bands
s Tibial component rotational alignment
Cementing the Final Implants

If the trial reduction is satisfactory, the final implants are called for and
opened from sterile packing. The trial prostheses are removed and the
knee is thoroughly irrigated with pulsatile lavage. The cancellous surfaces
are thoroughly cleaned for good cement interdigitation. It is a good pro-
tocol to have every member of the surgical team change gloves prior to
handling the sterile prosthesis. Polymethyl-methacrylate bone cement is
mixed as appropriate, and time since mixing is tracked. We prefer to com-
plete cementation of all components using a single 40 g mix of cement.
We start with patellar cementing at about 1 min after mixing (if patella
is being resurfaced). Next we cement tibial component to be followed
by femoral component. It is vital that tibial component rotation is paid
attention to. While inserting femoral component, care is taken so that
the posterior condyles of the prosthesis do not scratch against the tibial
surface. All excess cement is removed carefully. We prefer to fit in final
polyethylene tibial insert before releasing the tourniquet. The knee is
maintained in full extension so that cement is pressurized. Tourniquet is
then released and haemostasis is achieved. Closure is done in layers with
a watertight closure of the arthrotomy.
Tips for Avoiding Intraoperative Complications

s Use good quality saw and drill system.
s Use new saw blade of correct thickness (usually 1.2 mm) for each case.
s Always measure the resected bone thickness of distal femur and prox-
imal tibia.
s Plan for the level of resection based on the ligamentous stretching.
s Protect patellar tendon and medial collateral ligament (MCL) while
resecting bone.
s Flexion and extension gap balancing is critical for function and long-
term survival of prosthesis.
s Patellar tracking depends on rotational alignment of both tibial and
femoral components. Internal rotation of both tibial and femoral com-
ponent is strictly avoided.
Cruciate Retaining Total Knee Arthroplasty

Posterior CR TKA has certain technical variations from PS TKA and can-
not be performed in all cases. If PCL is stretched or contracted significantly,
it is functionally incompetent. Generally, deformities more than 20° in any
plane warrant use of PS TKA.
As most of the surgical procedure is same, only the differences with the
PS TKA are discussed here.
Technique Variations for Cruciate Retaining Total Knee Arthroplasty

1. Distal femoral resection: For CR TKA, it is useful to be conservative
with distal femoral resection. As stated earlier, during PS TKA, resec-
tion of PCL can increase flexion space by 2–4 mm and to increase the
extension apace, extra distal femoral resection may be beneficial. For
CR TKA, such adjustment is not likely, hence, conservative resection is
warranted.
2. Slope of tibial resection: PCL can act as a tether to the flexion gap
and it is important to reproduce native slope of the tibia to avoid flexion
gap tightness.
3. Balancing of PCL – Pull out lift off (POLO) test8: During trial
reduction, with patella relocated and not everted, laxity or tightness of
PCL is assessed as follows. In the pull out test, with knee in flexion,
attempt is made to pull out the tibial insert from under the femur. If
the tibial insert is easily pulled out, increasingly thicker inserts are tried
to achieve stability in flexion. In lift off test, if the trial tibial component
lifts off anteriorly, it suggests tightness of PCL. Another sign is failure of
tibial component to completely locate under the femoral component.
If PCL is tight, anterior and lateral fibers can be released from femur.
Excessive PCL release may make it incompetent. PCL laxity can also
be tested by applying posterior pressure to upper tibia to see if tibia
subluxes posteriorly. Significant posterior shift would suggest laxity of
PCL and may warrant the use of PS TKA.
REFERENCES
1. Insall JN, Scott WN, Ranawat C. The total condylar prosthesis: a report of two hundred
and twenty cases. J Bone Joint Surg 1979;61 A:173–80.
2. Insall JN, Hood RW, Flawn LB, Sullivan DJ. The total condylar prosthesis in gonarthro-
sis: a five to nine year follow up of the first one hundred consecutive replacements. J
Bone Joint Surg 1983;65 A:619–28.
3. Dennis DA, Komistek RD, Hoff WA. In vivo knee kinematics derived using an inverse
perspective technique. Clin Orthop Relat Res 1996;331:107–17.

4. Ranawat CS, Komistek RD, Rodriguez JA, Dennis DA, Anderle M. In vivo kinematics
for fixed and mobile-bearing posterior stabilized knee prosthesis. Clin Orthop Relat Res
2004;418:184–90.
5. Baier C, Springorum HR, Gotz J, et al. Comparing navigation based in vivo kinemat-
ics pre and post-operatively between a cruciate-retaining and a cruciate-substituting
implant. Int Orthop 2013;37:407–14.
6. Becker MW, Insall JN, Faris PM. Bilateral total knee arthroplasty: one cruciate retaining
and one cruciate substituting. Clin Orthop Relat Res 1990;271:122–24.
7. Swanik CB, Lephart SM, Rubash HE. Proprioception, kinesthesia and balance after
total knee arthroplasty with cruciate retaining and posterior stabilized prosthesis. J Bone
Joint Surg Am 2004;86A:328–34.
8. Scott RD, Chmell MJ. Balancing the posterior cruciate ligament during cruciate-retain-
ing fixed and mobile bearing total knee arthroplasty: description of pull-out lift-off and
slide-back tests. J Arthrop 2008;4:605–08.
Chapter 24
Mobile-Bearing Total Knee

Arthroplasty: Technique and
Clinical Results*
Charlie C. Yang, Douglas A. Dennis
INTRODUCTION
Early condylar total knee arthroplasty (TKA) designs were primarily
implanted in elderly, low-demand patients with debilitating pain and loss
of function. The excellent 10-to-15 year clinical outcomes in this patient
cohort1–5 has led surgeons to perform TKA on younger patients who have
higher functional demands and the need for increased implant longevity.
Increased patient expectations for a longer-lasting knee replacement have
driven advances in implant design and surgical technique.
Many first generation TKA designs resulted in early clinical failure
secondary to malalignment, instability and the use of excessive prosthetic
constraint. Premature aseptic component loosening was common due to
the increased stresses occurring at the fixation interface. Later iterations
of TKA focused on reducing constraint and conformity at the expense of
detrimental effects on the articular surface, resulting in accelerated polyeth-
ylene wear. The mobile-bearing (MB) TKA was designed with the inten-
tion of allowing increased implant conformity with reduced polyethylene
loads while concomitantly reducing stresses to the fixation interface. MB
TKA designs offer the theoretical advantage of increased implant conform-
ity and contact area while minimizing stresses transmitted to the fixation
interface.6 The dual articulation also reduces polyethylene cross-shear
stresses and wear to subsequently decrease the rate of revision TKA.7 This
uncoupled motion through the tibial tray-polyethylene bearing articulation
*Acknowledgement: We acknowledge the permission granted by World Scientific Publishing

Company to reproduce the parts of this chapter that appeared in “Raymond H. Kim and
Douglas A. Dennis. Mobile Bearing Total Knee Arthroplasty: Technique and Results. In: Giles
R Scuderi (Insall Scott Kelly Institute, USA), Alfred J Tria Jr (Robert Wood Johnson Medical
School, USA) Eds.The Knee: A Comprehensive Review. pp. 467-485. Copyright© 2014 World
Scientific Publishing Co.”
Mobile-Bearing Total Knee Arthroplasty: Technique and Clinical Results 281
theoretically minimizes the transfer of torsional stresses to the fixation

interface that are present with fixed-bearing TKA prosthetic designs.
This chapter addresses the surgical technique principles for implanting
a MB TKA and the clinical outcomes with use of these designs.
SURGICAL TECHNIQUE
Meticulous attention to symmetric ligament balancing, reproduction of
neutral mechanical alignment and creation of balanced flexion and extension
gaps are critical for the long-term success of both fixed-bearing and MB
TKA. Proper attention to these fundamental concepts will result in more
uniform loading of the articular bearing surface rather than placing exces-
sive eccentric loads on either the medial or lateral aspects of the polyethyl-
ene surface. Failure to obtain flexion–extension gap balance is of particular
importance in the use of a MB TKA due to the risk of bearing dislocation or
‘spin-out.’ The authors favor the use of a gap-balancing methodology rather
than measured resection techniques when implanting MB TKA because
adequate coronal plane stability is more reproducibly obtained.8
Balanced flexion and extension gaps can be achieved by several meth-
ods. The authors initially assess and balance the extension gap prior to
addressing the flexion gap and establishing the femoral component rota-
tion. After the distal femur and proximal tibial cuts are made, all remaining
osteophytes must be removed due to their tensioning effect on adjacent soft
tissue structures. The extension gap should then be assessed for gap height
and symmetry medially and laterally. This can be performed using spacer
blocks, laminar spreaders or other tensioning devices. If the extension gap
is asymmetric medially compared to laterally, appropriate releases should be
performed at this time to obtain a balanced extension gap. When implant-
ing an MB TKA, a laxity of 1–2 mm medially and laterally with firm varus
and valgus stress testing is desired.
Appropriate rotation of the femoral component is an essential com-
ponent of obtaining a balanced flexion gap. Numerous methods are
available to assist in gaining correct rotation of the femoral component
(Fig. 24.1).9–16 Techniques include: (i) use of cutting jigs which rotate the
femoral component a predetermined amount (typically 3–5°) externally
relative to the posterior condylar axis;9 (ii) femoral component placement
either parallel to the trans-epicondylar axis10–12 or perpendicular to the
anterior–posterior axis (Whiteside’s line);13 or (iii) by utilizing the gap-
3° external rotation vs. the

posterior condylar axis
Parallel to the
transepicondylar axis
Perpendicular to the
anterior-posterior axis
Fig. 24.1 Diagram demonstrating the transepicondylar (TEA), anterior–posterior (AP),

and posterior condylar (PCA) axes used for determination of femoral component rota-
tion when using a measured resection technique.
balancing method in which the femoral component is placed parallel to
the tibial cut with the medial and lateral collateral ligaments equally ten-
sioned.14–16 All methods have been shown to have potential shortcomings
and combined use of all rotational landmarks is wise. The critical step in
the use of gap-balancing involves positioning of the anterior–posterior
cutting block, which determines the rotation of the femoral component.
This block is positioned anteriorly or posteriorly to ensure that the flexion
gap height is equal to the exten-
sion gap height without notching
the femur. A decision about femo-
ral component size is confirmed at
this point. Using tensioning devices
(laminar spreaders, spacer blocks, or
a specific gap tensioning device), the
rotation of the anterior–posterior
cutting block is then appropriately
adjusted rotationally to ensure that
the flexion gap space itself is sym-
metric medially and laterally and
parallel to the tibial cut with each
Fig. 24.2 Intra-operative photograph collateral ligament equally tensioned
demonstrating the gap-balancing tech-
nique to establish femoral component (Fig. 24.2 ). Secondary checks
rotation to ensure a symmetric flexion are then performed to ensure rea-
gap medially and laterally and parallel to sonable rotational position relative to
the tibial cut with the collateral ligaments the transepicondylar and anterior–
equally tensioned.
posterior axes. Lastly, before anterior
and posterior femoral resections are

performed, the authors remove the
laminar spreaders and insert a spacer
block (same width as the extension
gap) between the inferior aspect of
the cutting block and the resected
tibia. The spacer block handle is
then torqued to assure symmetry of
the flexion gap (Fig. 24.3). Use of
this technique facilitates obtaining
balanced flexion and extension gap
heights, and a rectangular flexion
gap that is symmetric medially and
Fig. 24.3 Intra-operative photograph
laterally. If the anterior–posterior demonstrating placement of a spacer
cutting block is positioned paral- block (same width as utilized in creation
lel to the resected tibia and there of the extension gap) into the flexion gap
is substantial divergence from the to ensure appropriate width and sym-
metry before performing the anterior and
transepicondylar and anterior–pos- posterior femoral condylar resections.
terior axes, one of three things has
occurred. Either the axes have been constructed in error, there is an error
in the proximal tibial resection, or the flexion gap stabilizers (superficial
medial collateral ligament medially or lateral collateral ligament and pop-
liteus tendon laterally) are incompetent. Inability to obtain flexion–exten-
sion gap balance or substantial incompetence of the collateral ligamentous
structures should prompt consideration of using a fixed-bearing TKA or
use a more constrained MB device to reduce the risk of polyethylene
bearing spin-out. When equal flexion–extension gap balance cannot be
obtained, most commonly in cases with collateral ligament insufficiency,
the authors prefer the use of a constrained condylar rotating platform (RP)
TKA. In scenarios with severe deformities with tibial plateau defects and as
to which bone grafting or use of a modular tibial augment is required, the
authors consider use of a modular stem extension in these cases.
Large, posterior femoral osteophytes can impinge on the RP bear-
ing in deep flexion and should be removed. After making the anterior
and posterior condylar resections on the distal femur, the knee can be
placed at 90° of flexion with the flexion gap distracted with a laminar
spreader. A three-quarter-inch curved osteotome can then be used to
sharply remove the posterior osteophyte at the osteochondral junction
of both condyles (Fig. 24.4). The flexion and extension gaps can then be
Fig. 24.4 Intraoperative photograph demonstrating removal

of posterior femoral osteophytes using a curved osteotome.
reassessed to determine if further balancing is required. In cases with mas-

sive posterior compartment osteophytes, it is wise to attempt to remove
them before extensive soft tissue releases are performed since removal
of large osteophytes can have a dramatic effect on both the coronal and
sagittal plane soft tissue balance.
Due to the self-aligning mechanism of the RP polyethylene bearing
with the femoral component, tibial component rotation can be deter-
mined based on the anatomy of the resected tibial surface rather than
its position relative to the tibial tubercle. The self-aligning behavior of
the rotating bearing maintains congruency of the femorotibial articu-
lation during both flexion–extension and axial rotation of the knee,17
which is much more difficult to achieve in fixed-bearing TKA designs.
An additional advantage of the self-aligning feature of RP TKA systems
is facilitation of central patellar tracking.3,18 In a fixed-bearing TKA, if
substantial malrotation of the tibial component relative to the femoral
component is present (especially tibial component internal rotation), the
tibial tubercle can become lateralized, enhancing the risk of patellar sub-
luxation. An RP design, through bearing rotation, typically provides for
greater self-correction of rotational component malalignment, allowing
better centralization of the extensor mechanism. A study of over 1300
consecutive primary TKAs performed at our institution comparing the
lateral release rates in fixed vs. MB TKA revealed a lateral release rate in
the fixed-bearing group of 14.3% (54 of 378) compared to 5.3% (50 of
940) in the MB group (p < 0.0001).18
CLINICAL OUTCOMES
Excellent long-term clinical results with minimal loosening rates have been
reported in numerous studies of MB TKA. Callaghan et al.3 evaluated the
15-year results of the LCS RP design (Depuy, Inc., Warsaw, IN) and report-
ed no failures secondary to loosening, osteolysis, wear, or bearing instabil-
ity. In the initial early combined experience with the low contact stress
(LCS) meniscal bearing and RP systems, Buechel and Pappas2 reported
95.1% and 98.2% (cemented and cementless) good to excellent results at
a follow-up period of up to 10 years. When evaluating only the RP LCS
system, Buechel et al.19 reported survivorship rates of 97.7% at both 10 and
20 years with end-points defined as revision for any mechanical reason or
a poor clinical knee score. Survivorship of the cementless LCS RP system
with loosening as the end-point was determined to be 99.4% at 20 years.1
Various studies evaluating primary TKA using the RP system reported no
evidence of radiographic loosening, even at 20-year radiographic follow-up
and report that revision TKA was required in 0–0.2% due to aseptic loosen-
ing.1–3,19 Carothers et al.20 performed a meta-analysis of clinical results of
MB TKA and found survivorship of RP designs to be 96.4% at 15 years.
Mean component loosening was 0.33%. Bearing complication rate (frac-
ture or spin-out) in studies reported after 1995 was 0.1%
SUMMARY
Basic science evaluation of MB TKA demonstrates many potential advan-
tages including reduced polyethylene wear by providing improved implant
conformity, reduced cross-shear stresses and reduced stresses in the pres-
ence of femoral condylar lift-off. Additionally, lessened fixation stresses are
observed. Use of a surgical technique which assists in obtaining flexion–
extension gap balance and symmetry is critical to obtain successful results.
Multiple studies have demonstrated excellent long-term clinical results
with a very low incidence of aseptic loosening, polyethylene wear, bear-
ing instability, or failure due to backside wear of the mobile polyethylene
bearing.
REFERENCES
1. Buechel FF, Sr. Long-term follow-up after mobile-bearing total knee replacement. Clin
Orthop 2002;404:40–50.
2. Buechel FF, Pappas MJ. New Jersey low contact stress knee replacement system:
Ten-year evaluation of meniscal bearings. Orthop Clin North Am 1989;20:147–77.

3. Callaghan JJ, O’Rourke MR, Iossi MF, Liu SS, Goetz DD, Vittetoe DA, Sullivan
PM, Johnston RC. Cemented rotating-platform total knee replacement. A concise
follow-up, at a minimum of fifteen years, of a previous report. J Bone Joint Surg (Am)
2005;87(9):1995–98.
4. Ranawat CS, Boachie-Adjei O. Survivorship analysis and results of total condylar knee
arthroplasty: Eight- to 11-year follow-up period. Clin Orthop 1998;226:6–13.
5. Schai PA,Thornhill TS, Scott RD. Total knee arthroplasty with the PFC system: Results at
a minimum of ten years and survivorship analysis. J Bone Joint Surg (Br) 1998;80:850–58.
6. Bottlang M, Erne OK, Lacatusu E, Sommers MB, Kessler O. A mobile-bearing knee
prosthesis can reduce strain at the proximal tibia. Clin Orthop Relat Res 2006;447:105–11.
7. Callaghan JJ, Insall JN, Greenwald AS, Dennis DA, Komistek RD, Murray DW,Bourne
RB, Rorabeck, CH, Dorr, LD. Mobile-bearing knee replacement: Concepts and results.
8. Dennis DA, Komistek RD, Kim RH, Sharma A. Gap balancing versus measured resec-
tion technique for total knee arthroplasty. Clin Orthop Relat Res 2010;468(1):102–07.
9. Nagamine R, Miura H, Inoue Y, Urabe K, Matsuda S, Okamoto Y, Nishizawa M,
Iwamoto Y. Reliability of the anteroposterior axis and the posterior condylar axis for
determining rotational alignment of the femoral component in total knee arthroplasty.
J Orthop Sci 1998;3(4):194–98.
10. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determining the rota-
tional alignment of the femoral component in total knee arthroplasty using the epicon-
dylar axis. Clin Orthop Relat Res 1993;(286):40–7.
11. Griffin FM, Math K, Scuderi GR, Insall JN, Poilvache PL. Anatomy of the epicondyles
of the distal femur: MRI analysis of normal knees. J Arthroplasty 2000;15(3):354–59.
12. Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE. Rotational landmarks
and sizing of the distal femur in total knee arthroplasty. Clin Orthop Relat Res 1996;
(331):35–46.
13. Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in
valgus total knee arthroplasty. Clin Orthop Relat Res 1995; (321):168–72.
14. Dennis, DA. Measured resection: an outdated technique in total knee arthroplasty.
Orthopedics 2008; 31(9):940, 943–44.
15. Fehring TK. Rotational malalignment of the femoral component in total knee arthro-
plasty. Clin Orthop Relat Res 2000;380:72–9.
16. Katz MA, Beck TD, Silber JS, et al. Determining femoral rotational alignment in total
knee arthroplasty: reliability of techniques. J Arthroplasty 2001;16(3):301–05.
17. Stukenborg-Coleman C, Ostermeier S, Hurschler C, Wirth CJ. Tibiofemoral contact
stress after total knee arthroplasty: comparison of fixed and mobile-bearing inlay designs.
Acta Orthop Scand 2002;73:638–46.
18. Yang CC, McFadden LA, Dennis DA, Kim RH, Sharma A. Lateral Retinacular Release
Rates in Mobile- versus Fixed-bearing TKA. Clin Orthop Rel Res 2008;466(11): 2656–61.
19. Buechel FF Sr, Buechel FF, Jr, Pappas MJ, Dalessio J. Twenty-year evaluation of the New
Jersey LCS rotating platform knee replacement. J Knee Surg 2002;15:84–9.
20. Carothers JT, Kim RH, Dennis DA, Southworth C. Mobile-bearing total knee arthro-
plasty: a meta-analysis. J Arthroplasty 2011;26(4):537–42.
Chapter 25
Management of
Tibial Bone Defects
Rajesh N. Maniar, Vipan Kumar
INTRODUCTION
Tibial defects are often encountered at primary knee arthroplasty, in rela-
tion to either severe deformity, osteoporotic bone, osteonecrosis, bone cyst
or old injury. They pose a unique problem to achieving adequate support
and fixation of the tibial component. One needs to address them effectively
to obtain a uniform and successful outcome.
CLASSIFICATION
Based on Location of Defect
Peripheral defects: commonly seen with varus knee; they typically appear
posteromedial or anteromedial in location (Fig. 25.1).
Central defects: commonly seen in valgus knee and rheumatoid knee
(Fig. 25.1).
The significance of location of
the defect is that a central defect
would have a good cortical rim and
would only need to be filled with
either cement or cancellous bone
graft, whereas the peripheral defect
would need additional support with-
out which there is a risk of implant
collapse into the defect.
Fig. 25.1 Radiograph showing one side Based on Size of Defect

varus deformity with other side valgus Rand classified these defects accord-
deformity. Corresponding cut bones in
the inset show peripheral defect on varus ing to the extent of involvement
side and central defect on valgus side. of the tibia or femoral condyle
(Table 25.1).1 Rand classification helps to grade the defect and manage it
accordingly. Larger the defect, less is the support to the implant and more
aggressive is the treatment needed.
Table 25.1 Rand classification of bone loss1

Type Single condyle/hemiplate Depth (mm)
a: Intact peripheral rim involvement
b: Deficient peripheral rim
1.(a,b) Minimal <50% <5
2.(a,b) >50–<70% 5–10
3.(a,b) >70%–<90% >10
4.(a,b) >90% >10
MANAGEMENT OPTIONS
There are several ways to address tibial defects effectively. First, one can
consider ways to minimize the defect, and then select the best option to
fill the residual defect. Finally, it is imperative to assess the need for addi-
tional support to the construct, which can be provided by a tibial stem
extension.
Tricks to Minimize the Extent of Defect

1. Tibial resection through the base of defect.
2. Down sizing or Lateral translation of tibial component.
Tibial Resection Through the Base of Defect

Tibial resection through the base of defect is easy and therefore often a
practised method to deal with eliminating bone defect. However, resection
level should remain proximal to the Gerdy’s tubercle, otherwise function of
the ilio-tibial band would be compromised. It should be noted that with
greater tibial resection, the size of the component would also decrease,
reducing contact area and increasing per unit load. Besides, the tibial sur-
face becomes weaker if subchondral bone is completely removed. It has
been documented that the strength of cancellous bone in the proximal
tibia decreases rapidly 5 mm distal to the subchondral bone.13 Hence extra
bone resection should not be the preferred method for managing bone
deficiency (Fig. 25.2).
Management of Tibial Bone Defects 289
Advantage Disadvantages
1. Easy 1. Smaller size tibial tray, more load on
implant and bone.
2. Weakened support for tibial tray with
greater tibial resection.
A distal tibial cut should be avoided as far as possible, also because

in these cases with severe deformity the knee is already lax on the
lateral side. A distal tibial cut would necessitate a thicker poly. Hence,
tibial cuts should be limited in depth, and one of the options described
later should rather be used to deal with the residual defect left after the
limited tibial cut.
Fig. 25.2 Radiographs showing the level of tibial cut. Image

on the right is the preferred level.
Lateral Translation of Tibial Component
Rationale
Lateralization of the smaller tibial component reduces the extent of periph-
eral bone defect under it (Fig. 25.3). Lotke presented a study on this tech-
nique in two groups, one had an average defect of 13.5 mm, other group
had a defect of 27.5 mm. There were no failures in the either group but
the overall knee score was better with lesser defect.17
Advantages Disadvantages
1. Quick, not time consuming. 1. A smaller size tibial tray implies more
2. Easy to perform. load on implant and bone.
3. Economical. 2. Changes the axis of tibia.
3. Mechanically, it is not a sound technique.
Technique
1. If suitable, select one size smaller tibial component. Place it lateral most,
yet contained within the cut tibial surface.
2. There should be no overhanging of the plate on the lateral side.
Fig. 25.3 Downsizing the tibial component with lateraliza-

tion done to reduce the extent of peripheral tibial defect.
OPTIONS TO FILL THE DEFECT
Cementing or Cement with Screw

Use of cement in filling the defect is a viable option as cement can be
easily moulded to any size or dimension of the defect. Lotke et al., and
Ritter and Harty have observed good medium- or long-term results with
cement fill.4,16 However, the support provided by cement fill may not be
mechanically adequate.3,4 Lotke et al. described reasonable results with
cement but preferred bone grafting for defects greater than 20 mm.4 Elia
and Lotke found no difference in short-term results between the use of
cement and bone grafts for revision total knee replacement (TKR) and
small defects.5
In a cadaveric study comparing five different techniques for recon-

struction of medial tibial plateau bony defects, it was reported that tibial
component displacements under axial and varus-directed loads, respec-
tively, were 100% and 100% for the cement alone construct, 70% and
72% for cement with screw augmentation, 32% and 44% for the polym-
ethylmethacrylate (PMMA) wedge, 17% and 32% for the metal wedge,
and 9% and 17% for the custom implant. The cement alone construct
provided least stability.3 Cement is not a biological scaffold, it may cause
thermal necrosis of the surrounding bone and damage blood supply to
the bone, which could be a cause for long-term loosening of the pros-
thesis.8 However, cement can achieve similar stability as impaction bone
grafting and structural allografting when used for a 4-mm medial tibial
bone defect.2
For small bone defects, cement with screw fixation resulted in 30% less
displacement of the prosthesis than cement alone in tibial wedge defect
reconstruction.3,9 In 57 patients with tibial defects of mean 9 mm height,
followed up for a minimum of 3 years, 25% had nonprogressive radiolu-
cency at the cement interface, but none of the components failed.15 There
was no progression of radiolucent lines in either the bone–cement or the
cement–prosthesis interface after 7 years.17 The radiolucency probably
existed at the time of surgery and could be due to poor penetration of the
cement into sclerotic bones.18 Radiolucent lines can also occur because
cement contracts on final setting. It is thus advocated to make multiple
holes on the tibial bed for better penetration of the cement.
Authors recommend the use of cement alone only in defects less than
5 mm (Fig. 25.4).
For defects greater than 5 mm, if one opts to use cement, a stabilizing
screw should be additionally used to strengthen the construct.
Fig. 25.4 Intra operative photographs showing a small (<5 mm) peripheral tibial defect,
before and after filling with cement.
1. Easily available. 1. During pressurization, lamination can
2. Cement can be moulded occur with risk of fragmentation.6
to any size or dimension. 2. Thermal necrosis caused by cementation.
3. It provides inadequate mechanical support.
4. Radiolucent lines often appear under-
neath the implant.
Technique
1. The defect area must be made raw so as to remove worn out cartilage
and expose the bone. Multiple 3–4 mm drill holes are then made on
the surface, not deeper than 4 mm.
2. Peripheral defects may be converted to defects with vertical and hori-
zontal walls, so as to convert shearing forces to compressive forces.
3. Pulsatile lavage is used to remove blood, fat, debris as proper cleaning of
cancellous bone permits penetration of cement.
4. Mixed cement should be applied in the doughy state using manual pres-
surization. Ideal cement penetration should be around 3–4 mm.
5. If defect is greater than 5 mm in depth, one or two cancellous screws
should be inserted depending on the extent of the defect. They should
be inserted prior to cement application, and care should be taken in
their placement relatively in center of the defect and ensuring that they
do not restrict full sitting of the implant.
Bone Grafts
Rationale
Bone graft is the most biologic solution to fill defects. It can be either
autogenous or allograft. In primary total knee arthroplasty (TKA), mostly
autogenous graft is preferred, as it is easily available and also the most eco-
nomical. It can be fashioned to match the defect.
1. Economical, readily available. 1. Additional time.
2. Preserves strong subchondral bone. 2. Exacting technique.
3.Versatility to fit any shape and size of 3. Potential risk of resorption,
defect. collapse or nonunion of graft.
4. Provides uniform thickness of
cement under implant.
Dorr et al. report viable integration of the graft in biopsy specimens in

their study.10 They reported 90–95% success in use of autografts, provided
certain principles are followed, which include:
1. Adequate surface preparation of host bone to expose a viable host bed.
2. Definition of defect and preparation of the graft so that excellent fit and
fixation is obtained.
3. Coverage of graft by the component to prevent resorption of
unstressed graft.
4. Protection of graft from overload by correct alignment of the compo-
nent and limb and by limited weight bearing until union occurs.
5. Protection of the graft by use of a stemmed component when indicated.7
Resorption or failure of incorporation of graft is the primary concern
regarding this technique. Laskin et al. have pointed concern over the long-
term fate of bone grafts in their report.11 Dorr et al. reported two cases of
nonunion in their series of 24 patients, describing three important reasons
for failure which were all related to surgical technical aspects.10
1. Abnormal alignment
2. Bad preparation of bed
3. Poor graft fit
Besides these, one also needs to avoid seepage of cement in between the
graft and bone interface. The authors have evolved a detailed technique of
autologous bone grafting for severe medial tibial bone loss, to overcome the
above pitfalls. The technique has been successfully used in over 100 cases
over last 10 years.
The steps of authors’ technique are as follows.
Step 1: Harvesting the graft: Posteromedial femoral condyle (which
is excised as a part of femoral preparation) is used. It is removed with care
Fig. 25.5 Harvesting of posterior medial femoral condyle as

bone graft.
Fig. 25.6 Preparation of the tibial defect after implants trial

is done.
so as not to damage its cancellous surface, and is preserved carefully in a

wet sponge on a back table (Fig. 25.5).
Step 2: Preparation of the defect: Tibial defect is prepared only
after completion of all cuts, insertion of trial components and balancing
of ligaments (Fig 25.6). Tibial defect base is first resected using an oscil-
lating saw to remove the eburnated bone, exposing cortico-cancellous
surface. Multiple drill holes (2 mm) are made in the prepared base of the
defect.
Step 3: Bone grafting: Bone graft is placed with cancellous bone
opposing the prepared cancellous bed. It is held temporarily with two
K-wires (2–3 mm) (Fig. 25.7). Bone graft is resected flush with the cut
tibial surface using an oscillating saw. Trial tibial component is placed to
assess the adequacy of resection to ensure full sitting of the implant. A
point is identified in the middle of the graft but within the periphery of
the tibial component coverage for passage of a compression screw. A 3.5
or 4.5 mm cortical or cancellous screw is selected depending on the size
A B C
Fig. 25.7 (A–C) Sequence of graft fixation to fill the defect and tibial component
implantation.
of the defect and graft. This is passed after drilling and tapping in a direc-
tion perpendicular to the slope of the defect so as to achieve adequate
compression at the graft–host site (Fig 25.7). The screw head needs to
be buried in the graft, below the level of the tibial cut. During this step,
there is a potential risk of splitting the graft, and care must be taken to
prevent it particularly if graft is small or porotic. This can be done by
pretapping the screw path fully and doing the final tightening and sinking
of the screw slowly.
Step 4: Implanting tibia: Tibial component is inserted after lavage
and drying of bone, using bone cement.
Step 5: Final preparation: After hardening of the cement, K-wires are
removed and the graft that is uncovered at the periphery of the component
is resected flush to the tibial tray and in line with the host bone (Fig. 25.7).
The average additional time taken for the procedure is about 8–10 min.
RESULTS
We have used this technique in over 100 patients successfully. Adhering
to surgical technique steps has avoided any failure on the table to fill the
defect adequately. Position of the graft, the screw and the implants remained
unchanged in the follow-up period. There has been no failure of graft
incorporation since the technique ensures that graft is well compressed to
the host bones, and also adequately covered and loaded by the tibial tray. In
the three instances, wherein the posteromedial femoral condyle resected was
small to cover the defect, the notch bone removed as a part of preparation for
posterior stabilized (PS) femoral component was utilized. In the immediate
postoperative period, the density of the graft appeared significantly less com-
pared to surrounding thickened corticalized tibial bone. However, with time
(about 6–9 months), the graft incorporated with the host bone as evidenced
Fig. 25.8 Bone-grafted medial tibial defect, gradually united

(3 months) and densified (9 months).
by crossing trabeculae (in some cases with posteromedial defect, it was nec-
essary to take an oblique view to clearly visualize this on radiograph). Over
time, we observed an increase in the density of the graft and it matched the
surrounding bone (Fig. 25.8).
We reviewed our very first 10 patients who had completed 10
years post surgery for the purpose of this chapter. Three patients had
died and other seven were evaluated both clinically and radiologi-
cally. Average preoperative knee score of 33, was 97 at 10 years post-
operatively. The average preoperative function score of 47, was 73 at
10 years postoperatively. Radiologically, the bone graft–native tibial
interface was indistinguishable and there was no resorption of graft
(Figs 25.9 and 25.10).
Fig. 25.9 Preoperative medial tibial defect treated with

bone graft, at 5 years and 10 years.
Fig. 25.10 Large preoperative medial tibial defect. Immediate post op X-ray showing
bone graft in position, 6 months X-ray showing union of the graft and its appearance
at 11 years.
Metal Wedge Augment

Rationale
Metal wedge augmentation of bone defects is another alternative (Fig. 25.11).
Metal wedges not only fill the defect but also offer an excellent load transfer
from implant to bone.3 Brooks et al. have supported the use of metal wedge
undersurface augmentation of tibial tray for bone defects. They have report-
ed in their study the incidence of nonprogressive radiolucencies (< 1 mm) to
be low in primary knees (16%).3 Brand et al., and Lee and Choi reported the
incidence of nonprogressive radiolucent lines of approximately 11–27%.14,22
1. Efficient load transfer from implant 1. Radiolucent line under implant
to bone as compared to cement;3 bone interface can lead to loos-
no thermal necrosis of bone. ening of prosthesis.15
2. Does not require incorporation as 2. Increased cost.
required by grafts; no issue of 3. Not applicable to central defects.
collapse or non-union. No graft 4. Corrosion or fretting between
site co-morbidity. tray and augment.
3. Options available for size and shape. 5. Often, more bone is removed to
fit the wedge well. Using smaller
wedges may need additional
cement fill, defeating the purpose.
Augments can be various dimensions of blocks or wedges. Augments
are suitable for peripheral defects greater than 5 mm where there is ten-
dency for the trial to displace at the time of reduction.9 Chen and Krackow
have reported that rectangular metal blocks placed on the surface of bone
defects vertical to the loading direction were more effective in reducing
shear forces than metal wedges placed on the oblique surface of defects.12
Technique
1. The defect is measured after completing the tibial cut.
2. Matching metal wedge trial is selected.
3. Undersurface of trial wedge is painted with methylene blue.
4. Trial wedge is fixed with trial tibial tray and placed over the surface.
5. Methylene blue will indicate where there is contact with bone, indicat-
ing area where load gets transferred from wedge to bone.
6. Bone is cut using a saw or burr to maximise the area of contact.
7. Trial sitting is repeated.
8. Once defect matches with

wedge, drill holes are created in
the sclerotic bone.
9. Cementing of the final tibial
component with incorporated
wedge is done.
Custom-made Prostheses
These are rarely employed in prima-
ry TKR, but can be useful for man-
aging tibial defects greater than 1.5
cm in depth. They have the added
advantage of uniform transmission
of force between implant and bone.
However, they are expensive and
errors can occur during custom-
ization, which may render them
unsuitable at the time of surgery.1
Long-term results are not satisfacto-
ry. Pour et al. reported in their study,
in which majority of patients were
revision TKRs, that the survival rate
was 68% at 5 years and cautioned
regarding their use in active and
younger individuals.19
Metaphyseal Sleeves
Metaphyseal sleeves play a very sig-
nificant role in reconstruction of
osseous defects during revision TKR.
Fig. 25.11 Post op X-ray depicting use of They have excellent potential for
metal wedge to fill the defect. biologic fixation with porous coating.
Tantalum metal has been demon-
strated in a wide variety of adult reconstructive applications. Cone or sleeves
increase the contact area between implant and the host bone, and they act as
supports; in addition, they have the property of allowing bone in growth.21
Their use can be extended to primary TKA in selected patient. However,
their use would increase the cost significantly.
ADDITIONAL SUPPORT FOR CEMENT, BONE GRAFT

OR AUGMENT
Extended Intramedullary Stems

Stems can be utilized to manage large peripheral defects. They help protect
the defect by partially offloading it. In these cases, the diaphyseal cortical
bone is intact; the extended stem engages the cortex and supports the tibial
tray. Length of the stem should be adequately selected to relieve the stress in
deficient bone. The decision to use a stem or not is most critical. Authors
make this decision as follows. After preparation of the tibia and with trial
implant in place, apply a vertical pressure on the tray overlying the medial
defect. If the tray sinks into the defect, which is evident by tray base lifting
off from the bone on the lateral side, the authors decide to use the stem
(Fig. 25.12).20
B C
Fig. 25.12 (A) Trial implant in situ, vertical pressure causing
it to sink into the defect with lift-off of the opposite margin
(arrow). (B) Trial implant with stem extender in situ, giving
stability with no sinking on vertical pressure. (C) Post op
X-ray of same patient.
Soft Tissue Release

Role of balancing the soft tissue around the joint for the successful out-
come in TKA is well established. In the varus knee, the anatomic struc-
tures on the medial side of knee are contracted. A step-wise sequential

release of medial structures in a varus knee should include excising medial
osteophytes, releasing deep medial collateral ligament (MCL), releasing
posteromedial corner and lastly releasing the superficial MCL. If the knee
is left tighter on the medial side, there would be increased load transmit-
ted through medial side, overloading the defect area, potentially leading to
failure. Therefore, in the management of tibial defects, a crucial last step is
to ensure a well balanced knee by adequately addressing the tight medial
structures.
CONCLUSION
Tibial defects in arthritic knee significantly affect the final outcome in
TKA. We recommend the use of cement to address defects less than 5
mm. For defects greater than 5 mm but less than 10 mm, one can opt to
use cement with an additional screw support. For larger defects more than
10 mm, metal wedge or bone graft should be considered. We prefer bone
grafts for their obvious biological advantage. The technique described
here has worked well, is reproducible and quick and has given excellent
long-term results too. As a final step, we emphasize the need for adeqate
ligament balancing and utilizing an additional stem support.
REFERENCES
1. Rand JA. Bone deficiency in total knee arthroplasty. Use of metal wedge augmentation.
Clin Orthop Relat Res 1991;271:63–71, ISSN 1528-1132.
2. Toms AD, Barker RL, McClelland D, Chua L, Spencer-Jones R, Kuiper JH. Repair of
defects and containment in revision total knee replacement: a comparative biomechani-
cal analysis. J Bone Joint Surg Br 2009;91:271–77.
3. Brooks PJ, Walker PS, Scott RD. Tibial component fixation in deficient tibial bone
stock. Clin Orthop 1984;184;302.
4. Lotke PA, Wong RY, Ecker ML. The use of methylmethaacrylate in primary total knee
replacement with large tibial defects. Clin Orthop;1991:270:288–94.
5. Elia EA, Lotke PA. Results of revision total knee arthroplasty associated with significant
boneloss. Clin Orthop 1991;271:114–21.
6. Scunder GR, Insall JN, Haas SB, Becker-Fluegel MW, Windsor RE. Inlay autog-
enous bone grafting of tibial defects in primary total knee arthroplasty. Clin Orthop
1989;248:93–7.
7. Dorr LD. Bone grafts for bone loss with total knee replacement. Orthop Clin North Am
1989;20:179–87.
8. Persson BM, Wouters HW. Curettage and acrylic cementation in surgery of giant cell
tumors of bone. Clin Orthop Relat Res 1976;120:125–33.
9. Cuckler JM. Bone loss in total knee arthroplsty: graft augment and options.
J Arthroplasty 2004;19(Suppl):56–58.
10. Dorr LD, Ranawat CS, Sculco TP, et al. Bone graft for tibial defect in total knee
arthroplasty. Clin Orthop 1986;205.
11. Laskin RS, Kupferman S, Luster S, Thal R. Total knee arthro-plasty in the presence of
large bony defects and marked instability. Presented at the Knee Society, February 12,
1990, Las Vegas, Nevada.
12. Chen F, Krackow KA. Management of tibial defects in total knee arthroplasty: a biome-
chanical study. Clin Orthop Relat Res 1994;(305):249–57.
13. Harada Y, Wevers HW, Cooke TD. Distribution of bone strength in the proximal tibia. J
Arthroplasty 1988;4:167.
14. Brand MG, Daley RJ, Ewald FC, Scott RD. Tibial tray augmentation with modular
wedges for tibial bone stock deficiency. Clin Orthop 1989;270:288–94.
15. Ritter MA. Screw and cement fixation of large defects in total knee arthroplasty. J
Arthroplasty 1986;1:125–29.
16. Ritter MA, Harty LD. Medial screws and cement: a possible mechanical augmentation
in total knee arthroplasty. J Arthroplasty 2004;19:587–89.
17. Lotke P. Tibial component translation for bone defects. Orthop Trans 1985;9:425.
18. Ritter MA, Harty LD, Davis KE, Meding JB, Berend M. Simultaneous bilateral, staged
bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am
2003;85:1532–37.
19. Pour AE, Parvizi J, Slenker N, Purtil JJ, Sharkey PF. Rotating hinged total knee replace-
ment: use with caution. J Bone Joint Surgery (Am) 2007;89-A:1735–41.
20. Bourne RB, Finlay JB. The influence of tibial component intramedullry stems and
intramedullry stems and implant-cortex contact on the strain distribution of the proxi-
mal tibia following total knee arthroplsty. An in vitro study. Clin Orthop 1986;208:95.
21. Bobyn JD, Oggie RA, Krgier JJ, Lewallen DG, Hanssen AD, Lewis RJ, Unger AS,
O’Keefe TJ, Christie, Nasser S, Wood JE, Stulberg SD, Tanzer M. Clinical validation of
a structural porous tantalum biomaterial for adult reconstruction. J Bone Joint Surg Am
2004;86(Suppl 2):123–29.
22. Lee JK, Choi CH. Management of tibial bone defects with metal augmentation in pri-
mary total knee replacement. A minimum five-year review. J Bone Joint Surg Br 2011;93-
B:1493–96.
Chapter 26
Total Knee Arthroplasty in

Fixed Flexion Deformity
S.K.S. Marya, Chandeep Singh
Flexion contracture is a common finding in the degenerative knee. Often,

flexion contracture is combined with angular deformities of the lower limb,
most commonly varus malalignment. The aetiology of a preoperative fixed
flexion deformity is multifactorial; bony impingement, posterior capsular
contracture, hamstring shortening and ligament contracture all contribute
to the inability to fully straighten the knee. Soft tissue contracture occurs in
patients with long-standing deformities from a variety of disease states such
as inflammatory arthritis, post-traumatic arthritis, immobility, haemophilia
and neuromuscular disorders.
The flexion deformity is graded as the degrees. A mild deformity is
considered to be 15° or less and is classified as Grade I. A moderate defor-
mity is considered to be between 15° and 30° and is classified as Grade
II. A severe deformity is considered to be greater than 30° and is classified
as Grade III.1 Each grade requires a slightly different surgical approach,
and accurately assessing the degree of flexion contracture will guide the
surgeon as the contracture is addressed with a combination of soft tis-
sue releases and bony resection. The exact assessment of the extent of the
deformity is made on the OT table under anaesthesia when the pain com-
ponent of the deformity has been negated (Fig. 26.1).
The clinical consequence of a
fixed flexion deformity of the knee
is that the quadriceps are forced
to continuously contract to avoid
buckling, leading to a greater ener-
gy expenditure for walking and
resultant fatigue. Residual flexion
contractures after total knee arthro-
plasty (TKA) can create similar
problems and force upon the con-
Fig. 26.1 True assessment of deformity tralateral limb.2,3 Although some
under anaesthesia.
Total Knee Arthroplasty in Fixed Flexion Deformity 303
contractures after total knee replacement (TKR) may eventually resolve,

if the lack of extension is greater than 15° three months postoperatively,
it is likely to persist.3,4
PREOPERATIVE EVALUATION
Patients should be properly evaluated with detailed medical history, includ-
ing restriction of activity and a thorough physical examination. The stan-
dard standing anteroposterior X-rays may not give us a correct picture,
as the flexion of the knee may show a reduction in the joint space as the
X-rays are not parallel to the joint line. X-rays done with properly directed
X-ray beams are important as knees with flexion contracture due to soft
tissue issues may show reduced joint space in improper X-rays. In properly
done X-rays, if joint space remains and the principal abnormality is soft tis-
sue contracture, then this knee could potentially be handled by soft tissue
release alone. This would be particularly important in younger patients of
juvenile rheumatoid arthritis.
Some surgeons have recommended preoperative casting to reduce the
contracture.5,6 There is very little written on casting for flexion contrac-
tures prior to joint arthroplasty. We prefer casting for younger patients with
recent contractures but do not utilize casting in patients who are older with
fixed deformities and significant joint destruction.
We need to decide whether to correct the deformity in one stage or in
two stages. The two-stage method consists of the release of the hamstrings
and posterior capsule followed by traction or serial casting in the first
stage.1 The advantage of this method is that it slowly extends the posterior
neurovascular structures, and hence, the risk of neurovascular complica-
tions is decreased. The drawback of this method is that two operations are
required, which may increase the risk of infection and may cause instabil-
ity. Furthermore, the flexion contracture may not be completely corrected
with this method.
SURGICAL STEPS
Surgical technique is initiated as with a measured resection technique with
bone cuts in the same dimension as with the prosthesis. In general, the
exposure is less of a worry as most of these knees have good flexion unless
they are a stiff knee (which is a separate chapter). Once the proximal tibial
and distal femur cuts are done, osteophytes from the posterior femoral
condyles are removed using an osteotome. Flexion and extension gaps are
then assessed.
Role of posterior cruciate ligament (PCL) is still debatable in a flexion
deformity as its release leads to an increase in the flexion gap and does
not play a role in the extension gap6; however, the authors use posterior
stabilized knee in all cases. Further releases are carried out and the exten-
sion gap is assessed at every step. The first step in the releases is the removal
of the posterior osteophytes, which are often present and put tension on
the posterior capsule and prevent full extension. The authors perform the
removal of posterior osteophytes after the bony cuts have been made and
the knee is at 90° of flexion. Placing lamina spreaders on the cut surface
of the tibia and posterior femoral condyles, and a curved osteotome and
curette facilitate this process (Fig. 26.2).
If the knee still does not fully
extend, a posterior capsular release
is performed. The capsule can be
released from the posterior femoral
or proximal tibial attachments, but
the authors find it easier to per-
form the release off the tibia. With
the knee hyperflexed, the tibia can
be subluxated anteriorly with an
anterior drawer force. The capsule
Fig. 26.2 Clearing the posterior osteo-
is then released from the posterior
phytes with help of lamina spreader.
tibial surface using electrocautery.
The posterior femoral capsular release can be performed using an osteo-
tome while always staying in contact with the bone. A powerful trick is the
use of swabs in addition to the osteotome. This ‘volume’ distraction results
in a safe and soft release of the posterior capsule.
If the extension gap is still tight then an additional distal femur cut of
2 mm can be planned as it affects the extension gap only. A 2 mm of distal
resection is equivalent to about 10° increase in extension.7,8 However, more
than 6 mm of resection is not recommended as this would elevate the joint
line impacting the joint biomechanics and may also interfere with the col-
lateral attachment. In certain situations where the surgeon finds flexion gap
to be excessive on the table, it may be useful to use a posterior offset stem
to posteriorize the femoral component and reduce the flexion gap without
affecting the extension gap (Fig. 26.3).
A B
Fig. 26.3 (A) Increase in flexion gap. (B) Flexion gap reduced by posteriorizing the femo-
ral component (with an offset stem).
The last resort is the tenotomy of medial head of gastrocnemius, which

is rarely necessary. In cases of severe deformities, we have to try and get
a balance between a fully extended knee and the use of constraint in the
implant. The overzealous balancing of the flexion and extension gaps have
to be weighed with the stability of the knee joint and also the preservation
of the neuro vascular structures in cases where flexion deformity is more
than 60°. However, in case of severe deformities, an option of constraint
implant in the form of rotating hinge needs to be kept.
Precautions while implantation of the femoral component need to be
observed in knees with flexion deformity as a femoral implant in flexion
may lead to a residual flexion contracture. Also one needs to be careful
when applying force in attaining full extension while implantation or trial-
ing as that may compress anterior portion of tibial plateau.
The decision of how much to correct on table depends on the etiology
of the flexion deformity; in rheumatoid arthritis, some residual flexion of
about 10°–15° can be left on table, which can be gradually stretched out
in the post op period. However, in osteoarthritic and post-traumatic cases,
it is advisable to get a full correction on table as that is going to be a final
correction. However, there are studies that report improvement in flexion
contracture even in osteoarthritic knees up to 1 year in follow up.9,10
POSTOPERATIVE MANAGEMENT
The degree of initial deformity affects the postoperative management.
We must be cognizant of the postoperative measures necessary to avoid a
residual flexion contracture. In mild deformities, keeping a bolster under

the ankle and early regimen of exercises to achieve full extension suffice. In
moderate to severe cases, use of night splints and/or post op braces may be
needed. A watch needs to be kept for a recurrence of the deformity and/or
extensor lag in these patients. In rheumatoids with severe deformity pre op,
we prefer to keep the knee flexed in the initial post op period and gradually
extend in the next 2 weeks.
The need to watch for neurovascular injuries or compromise cannot be
overemphasized in such cases, and if there is a nerve injury, then the patient
may need to be put in some flexion at the knee.
SUMMARY
Fixed flexion deformities of the knee can be functionally limiting and
physically debilitating. After TKR, residual flexion contractures are associ-
ated with poorer clinical outcomes. The algorithm for correcting a fixed
flexion deformity begins with the recognition of the problem preop-
eratively. Depending on the severity of the deformity necessary, soft tissue
releases, additional distal femoral bone cut, hamstring release or the use
of a constrained implant may be necessary. The postoperative period is
tailored to maintain full extension and may involve the use of braces and
close monitoring.
REFERENCES
1. Krackow KA. Flexion contracture. In: The Technique of Total Knee Arthroplasty. St Louis:
Mosby,1990, pp. 282–94.
2. Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J
Bone Joint Surg Am 1975;57(7):961–67.
3. Aderinto J, Brenkel IJ, Chan P. Natural history of fixed flexion deformity fol-
lowing total knee replacement: a prospective five-year study. J Bone Joint Surg Br
2005;87(7):934–36.
4. Mitsuyasu H, Matsuda S, Miura H, Okazaki K, Fukagawa S, Iwamoto Y. Flexion con-
tracture persists if the contracture is more than 15° at 3 months after total knee arthro-
plasty. J Arthroplasty 2011;26(4):639–43.
5. Convery FR, Conaty JP, Nickel VL. Flexion deformities of the knee in rheumatoid
arthritis. Clin Orthop 1971;74:90–3.
6. Mihalko WM, Krackow KA. Posterior cruciate ligament effects on the flexion space in
total knee arthroplasty. Clin Orthop Relat Res 1999;(360):243–50.
7. Bengs BC, Scott RD. The effect of distal femoral resection on passive knee exten-
sion in posterior cruciate ligament retaining total knee arthroplasty. J Arthroplasty
2006;21:161.
8. Su EP. Fixed flexion deformity and total knee arthroplasty. J Bone Joint Surg Br
2012;94(11 Suppl A):112–25.
9. Firestone TP, Krackow KA, Davis JD, Toeny SM, Hungerford DS. The management of
fixed flexion contractures during total knee arthroplasty. Clin Orthop 1992;284:221–27.
10. Quah C, Swamy G, Lewis J, Kendrew J, Badhe N. Fixed flexion deformity fol-
lowing total knee arthroplasty. A prospective study of the natural history. The Knee
2012;19:519–21.
Chapter 27

Stiff Knee
Ashok Rajgopal, Vivek Dahiya, Attique Vasdev
TOTAL KNEE REPLACEMENT IN STIFF KNEES

Total knee replacement (TKR) is the treatment of choice for knee arthritis.
Numerous reports in the literature have proved the efficacy of TKR in alleviat-
ing pain on ambulation, improvement of ambulatory ability and improvement
of range of motion (ROM). TKR helps patients in performing their daily
activities. Among the patients who undergo TKR for arthritic knees, there is
a subset of patients having stiff knees preoperatively. Stiff knees are defined by
a reduction of ROM to 50º or less.1,2 Patients are troubled by their inability
to either bend their knees while sitting or they are unable to extend the knees
completely to walk comfortably. Knee flexion assumes a greater significance
in Asiatic communities wherein a good ROM is essential for their religious
and social commitments. These patients also benefit from a TKR as their pain
is reduced and the ROM increases even though the published literature does
report of increased complication rates and lesser gain in ROM postoperatively
when compared to patients who did not have a stiff knee preoperatively. The
causes of a stiff knee are numerous, namely, infectious adhesions, ankylosis as a
sequelae to rheumatoid arthritis or ankylosing spondylitis, (Fig. 27.1) previous
intra-articular trauma (Fig. 27.2), heterotopic ossification, etc.3
In this chapter, we will try to elucidate the management of a stiff knee.
A thorough preoperative assessment followed by meticulous surgery and
judicious implant selection will lead to a well-balanced knee. Intensive
physiotherapy will combine with the above to give satisfying results.
PREOPERATIVE ASSESSMENT
A stiff knee by description is defined as a knee with less than a 50° arc of
movement. Knees can be ankylosed in flexion or in extension. Knee joint
may be ankylosed in flexion because of contracture of posterior soft-tissue
structures, mechanical bone block, post high tibial osteotomy or juxta-
A B
C D
Fig. 27.1 Preoperative (A, B) and postoperative (C, D) X-rays of a post traumatic stiff knee.
articular adhesions; or it may be so in extension because of quadriceps

contracture, heterotopic ossification, patella baja, or intra-articular adhe-
sions. Patella baja can be both a cause and a consequence of a stiff knee.
It reduces the lever arm of the quadriceps and consequently its efficiency.
Preoperative assessment consists of a detailed clinical history, local
examination and radiology. The history should elucidate the cause of knee
stiffness. All previous interventions on the knee need to be documented.

Local examination concentrates on the skin condition, pre-existing scars,4,5
soft tissue adhesions, power of the quadriceps muscle and the neuro-vascu-
lar status of the limb. Of no less importance is the stability of the patello-
femoral joint. The ROM needs to be adequately documented.
Radiology includes a standing anteroposterior view, lateral view and
skyline views (if possible) of the knee. A full length standing X-ray of the
limb helps in preoperative planning. A computed tomography (CT) scan is
helpful in ankylosed knees to determine any bone defects in the subchon-
dral or metaphyseal region. These defects have a bearing on the inventory
A B
C D
Fig. 27.2 Preoperative (A, B) and postoperative (C, D) X-rays of a spontaneously anky-
losed knee.
of implants, stems, wedges, augments and constraints kept available in the

operating room.3
SURGERY AND IMPLANT SELECTION

The anaesthesia chosen is based on the individual status of comorbidities
and the American Society of Anesthesiologists (ASA) grades. We prefer a
combined spinal epidural anaesthesia as postoperative pain is easily taken
care of. Postoperatively, femoral nerve blocks and adductor canal blocks are
also used to take care of pain. Surgery is carried out under tourniquet in
a laminar flow operating room. A final examination under anaesthesia is
done prior to skin incision.
While making the skin incision, previous scars have to be taken into
consideration. If multiple scars are present, then the lateral most incision
is used. In most of the surgeries, a standard midline longitudinal skin inci-
sion6,7 can be used followed by a medial parapatellar arthrotomy. There is
a role of tissue expanders8,9 placed preoperatively in case of skin adher-
ence on account of previous surgeries or infection. Extensile approaches
(quadriceps snip,10 V-Y quadriceps plasty, tibial tubercle osteotomy,11 or
transepicondylar osteotomy with skeletonisation) are routinely required
to aid in patellar eversion.2,3,12–18 Quadriceps snip is the most commonly
performed extensile approach in our experience. It has an added advantage
in that no change in postoperative rehabilitation is needed. Adhesions in
the suprapatellar pouch are excised. In case of patello-femoral ankylosis, the
joint line is identified and an osteotome is used to break the ankylosis. One
must be careful to keep enough patellar thickness to prevent intraoperative
or postoperative fractures. The tibio-femoral joint line is easily identified in
case of a fibrous ankylosis. When there is a bony ankylosis, intraoperative
radiographs help in identifying the level of osteotomy. With the knee in full
extension, two osteotomies are made 1 cm apart and the bone is removed.
Medial proximal tibial soft tissues are released from the tibia to aid in
the delivery of the tibia anteriorly.3 This helps in flexion of the knee to
allow for subsequent preparation of the femoral and tibial surfaces using
intramedullary and extramedullary jigs, respectively. It is interesting to note
that the posterior cruciate ligament was seen in all the stiff knees that we
operated on. Flexion and extensions gaps are balanced (Figs 27.3 and 27.4).
The choice of implant after preparation of the surfaces is dictated by the
ligaments around the knee and the bone quality. In case of osteoporotic
bone, stem extensions may be needed. If the medial collateral ligament is
Fig. 27.3 Flexion gap. Fig. 27.4 Extension gap.
lax or damaged, then a constrained implant may be required. We do not

resurface the patella. At the time of trial implantation, we must assess the
stability of the knee joint in full extension, 30º and 90º flexion and patel-
lar tacking. The wound is closed over a drain in layers and a compression
dressing is applied prior to tourniquet deflation.
REHABILITATION
The goal of postoperative rehabilitation is to achieve maximal ROM and
independent ambulation. Weight bearing is started on the next day after
surgery and is as per pain tolerance. Knee ROM exercises are also started
and the patient is encouraged to actively flex the knee. Continuous
passive motion machines are also used in some cases. The use of a
quadriceps snip during the surgery does not change the postoperative
rehabilitation. Once the patient is discharged from the hospital, he/she is
routinely followed up to assess the ROM and pattern of gait. In case of
ROM < 80º by 6 weeks, a manipulation under anaesthesia is performed,
which results in a satisfactory ROM.3
COMPLICATIONS
Careful handling of the tissues prevents many a complications such
as skin necrosis, wound dehiscence and infection.2,4,12,14,19,20 Extensor
mechanism needs to be meticulously handled as the patellar tendon
can very easily tear away from the tibial tuberosity (Fig. 27.5) during
the initial surgical dissection,3 hence, the need for extensile approaches.
Postoperative stiffness is a common occurrence and sometimes needs
manipulation in the operating room.
Fig. 27.5 Patellar tendon avulsion.
REVIEW OF LITERATURE
Aglietti et al. in 1989 reported on their series of 20 stiff knees and six
ankylosed knees. The average gain of ROM was 46º (from 32º preopera-
tively to 78º postoperatively). A posterior stabilized implant was used in
all the knees.1
Montgomery et al. in 1998 concluded that TKR in stiff or ankylosed
knees leads to significant improvement in ROM. In 82 stiff knees (aver-
age ROM 36º), the postoperative ROM was found to be 93º (range 35º
to 130º).21
Kim et al. in 1999 followed up on 99 stiff knees for a mean period
of 8.9 years and reported on a significant increase in hospital for special
surgery knee scores, Knee Society knee scores and Western Ontario and
McMaster Osteoarthritis Index (WOMAC) scores following their TKR.12
Rajgopal et al. in 2005 published their results in 84 ankylosed knees.
They reported on an average gain of 61º in ROM after TKR. The knee
scores and the functional scores also had a significant gain.3
Bhan et al. in 2006 compared the increase in ROM in stiff and anky-
losed knees. The ROM in stiff knees increased from 35º–69º preopera-
tively to 1º–94º postoperatively. In ankylosed knees, the ROM increased
from 0º to 3º–77º postoperatively.22
Fosco et al. in 2011 compared the results of TKR in ankylosed knees
with those in flexible knees and found that there was a 25% complication
rate in the ankylosed knee group. A total of 92% of the ankylosed knees had
an excellent or good result compared to 96% in the flexible knee group.2
In conclusion, total knee arthroplasty offers a viable sustained option in

the management of these very disabled patients.
REFERENCES
1. Aglietti P, Windsor RE, Buzzi R, et al. Arthroplasty for the stiff or ankylosed knee. J
2. Fosco M, Filanti M, Amendola L, et al. Total knee arthroplasty in stiff knee compared
with flexible knees. Musculoskelet Surg 2011;95:7.
3. Rajgopal A, Ahuja N, Dolai B. Total knee arthroplasty in stiff and ankylosed knee. J
4. Della Valle CJ, Berger RA, Rosenberg AG. Surgical exposures in revision total knee
arthroplasty. Clin Orthop Relat Res 2006;446:59.
5. Scott RD, Siliski JM. The use of a modified V-Y quadricepsplasty during total knee
replacement to gain exposure and improve flexion in the ankylosed knee. Orthopedics
1985;8:45.
6. Insall JN. A midline approach to the knee. J Bone Joint Surg Am 1971;53:1584.
7. Barrack RL, Smith P, Munn B ,et al. Comparison of surgical approaches in total knee
arthroplasty. Clin Orthop Relat Res 1998;356:16.
8. Mahomed N, McKee N, Solomon P, et al. Soft tissue expansion before total knee
arthroplasty in arthrodesed knee. A report of two cases. J Bone Joint Surg Br
1994;76:88.
9. Manifold SG, Cushner FD, Craig-Scott S, et al. Long term results of total knee arthro-
plasty after the use of soft tissue expanders. Clin Orthop 2000:133.
10. Whiteside LA. Exposure in difficult total knee arthroplasty using tibial tubercle oste-
otomy. Clin Orthop 1995:32.
11. Garvin KL, Scuderi G, Insall JN. Evolution of the quadriceps snip. Clin Orthop
1995;131.
12. Kim YH, Cho SH, Kim JS. Total knee arthroplasty in bony ankylosis in gross flexion. J
Bone Joint Surg Br 1999;81:296.
13. Bae DK, Yoon KH, Kim HS, et al. Total knee arthroplasty in stiff knees after previous
infection. J Bone Joint Surg 2005;87:333.
14. Kim YH, Kim JS. Does TKA improve functional outcome and range of motion in
patients with stiff knees? Clinical Orthop Relat Res 2009;467:1348.
15. Camanho GL. Total arthroplasty in ankylosed knees: a case series. Clinics 2009;64:183.
16. Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis
and takedown of formal knee fusion. J Arthroplasty 2000;15:453.
17. Schurman II JR, Wilde AH. Total knee replacement after spontaneous osseous ankylosis:
a report of three cases. J Bone Joint Surg Am 1990;72:455.
18. Arsht SJ, Scuderi GR. The quadriceps snip for exposing the stiff knee. J Knee Surg
2003;16:55.
19. Naranja RJ Jr, Lotke PA, Pagnano MW, et al.Total knee arthroplasty in previously anky-
losed or arthrodesed knee. Clin Orthop Relat Res 1996;331:234.
20. McAuley JP, Harrer MF, Ammeen D, et al. Outcome of knee arthroplasty in patients
with poor preoperative range of motion. Clin Orthop Relat Res 2002;404:203.
21. Montgomery WH, 3rd, Insall JN, Haas SB, et al. Primary total knee arthroplasty in stiff
and ankylosed knees. Am J Knee Surg 1998;11:20.
22. Bhan S, Malhotra R, Kiran EK. Comparison of total knee arthroplasty in stiff and
ankylosed knees. Clin Orthop Relat Res 2006;451:87.
Chapter 28

Post High Tibial Osteotomy
Vikram I. Shah, Kalpesh Shah, L. Bharath, Ashish N. Seth
INTRODUCTION
Valgus producing osteotomy for the treatment of unicondylar osteoar-
thritis of knee is a well-accepted procedure. It is most commonly used
for delaying knee replacement in young and active patients. The results of
knee replacement after failed tibial osteotomy would be similar to that of
primary knee replacement, which is yet to be established. This fact assumes
more significance as with the advent of newer designs and better implants
for knee replacement in younger patients, the results have been good.
Nevertheless, when a patient with previous tibial osteotomy presents with
degenerative knee, replacement of the knee remains the most logical solu-
tion to be offered to the patient. When considering knee replacement in this
patient group, it should be borne in mind that this procedure remains techni-
cally more challenging than uncomplicated primary knee replacement. This
chapter deals with the technical aspect of knee replacement done in patients
with failed high tibial osteotomy (HTO) and its results.
PREOPERATIVE ASSESSMENT
As in all other cases, proper history and examination are invaluable in
planning further treatment. History should include symptoms prior to the
tibial osteotomy as well as relief obtained from osteotomy. Course after
the surgery, including any infection or prolonged discharge from surgical
site, should be actively inquired into. Examination of the first surgical scar
should be done to plan incision for the knee replacement. Discharge and
other signs of infection at the operative site should be noted. Assessment
of the status of ligaments and range of motion should be done to antici-
pate surgical difficulties. One should be vigilant to rule out extra-articular
causes of pain. Importance of spine and hip examination cannot be over-
emphasized. Radiographs are vital for surgical planning. Long leg hip-
knee-ankle X-ray helps in checking alignment and planning distal femoral

valgus angle. Any implant in situ should be noted and appropriate instru-
ments for removal should be procured as a rule.
Keep metal cutting instruments ready as a backup. Patella infera, tilting
of tibial plateau and shift in medullary canal should be noted (Fig. 28.1).
This will give an idea about the tibial cut as well as requirement of
special implants as augments or offset stems.
Fig. 28.1 Patella infera.
TECHNIQUE
Once the decision to proceed with knee replacement is made, it is imper-
ative to plan the procedure in detail. Diagnosis, clinical examination of
the knee and detailed study of radiographs must be undertaken. Active
infection should be ruled out; status of ligaments should be checked and
stress X-rays should be taken if ligament instability is suspected. In case of
excessive laxity, semiconstrained or constrained implant might be needed.
If the osteotomy has been fixed with a plate and screws, stem extension
might be necessary to bypass screw holes in order to avoid stress riser.
In case there is too much of tilting of the tibial plateau in coronal plane,
wedge augments might be necessary along with stem extension. In case
of nonunion at the osteotomy site, plates and screws will be required
along with the stem extension. The amount of tibial flare overhanging
outside the lateral tibial cortex in a post HTO may decide the necessity
of tibial implant with built in offset.
Total Knee Arthroplasty in Post High Tibial Osteotomy 317
Planning of the incision is equally important. In study conducted by

Jackson et al.,13 the higher complication rates following knee replacement
in post HTO cases were mainly due to wound complications. If previous
HTO has been performed using transverse incision, it can be ignored and
straight midline incision can be used (Fig. 28.2).
In case of lateral longitudinal
incisions, we prefer to go medially,
leaving adequate bridge of the skin
between the two incisions. Other
option in such cases is to go through
lateral parapatellar approach for knee
replacement. One needs to be well
versed with this approach before
embarking on it right away in com-
plicated cases, like the ones under
Fig. 28.2 Skin incision.
discussion. In case of oblique inci-
sion, we incorporate the lower limbs of the previous incision into the inci-
sion for knee replacement. Take care to intersect the previous incision at
the angle of 45º–60º to minimize wound complications. Similarly, in case
of inverted L-shaped incision, distal part of anterior midline incision can be
merged with the longitudinal limb of previous incision. Antibiotics, anaes-
thesia and preparation/draping are done in standard manner. Depending on
surgeons’ preference, tourniquet may or may not be used. We prefer to tie
tourniquet but inflate it only if there is any need during the procedure. The
incision is selected depending on the previous incision as discussed earlier.
In case the skin flaps are to be raised, care should be taken to keep the
plane of dissection below the deep fascia. Our choice of approach is medial
parapatellar arthrotomy. In most cases, the attachment of patellar tendon on
tibial tuberosity is broad and thin.This along with the difficult exposure due
to scarring increases the chances of patellar tendon avulsion. To avoid this,
we prefer to keep the distal part of arthrotomy more medial and use patel-
lar tendon protection pin, which is very helpful in protecting the patellar
tendon from avulsion (Fig. 28.3).
Subperiosteal elevation of medial sleeve is a task, which should be
patiently undertaken in this lot of patients. There is lot of scarring around
medial metaphysis due to previous surgery and care needs to be taken not
to disrupt medial collateral integrity while performing release (Fig. 28.4).
Fat pad release and freeing the lateral structure, which are gener-
ally scarred, help in the eversion of patella. Patello-femoral ligament is
Fig. 28.3 Patellar tendon pin. Fig 28.4 Medial release.
released. We use a retractor to subluxate tibia forward. This also causes

external rotation of tibial plateau and relieves some tension from patellar
tendon. Anterior cruciate ligament is excised. We routinely use cruci-
ate substituting design, and hence, release the posterior cruciate as well.
Lateral meniscus can be excised at this stage. Tibial cut is made using
extramedullary jig, keeping in mind the amount of bone expected to
be removed from medial, lateral, anterior and posterior sides as per the
preoperative planning. When the tibial plateau is tilted sloping anteriorly,
care should be taken to keep the thickness of tibial cut minimum with
less slope. In this case, the tibial cut surface looks exactly opposite to that
in primary knee replacement; here it is thicker posteriorly (Fig. 28.5).
In most of the cases, the tibial cut
is thicker medially. After the tibial
cut, the surface should be checked
with alignment rod and size of the
tibial tray; the one that can be used
should be noted. In cases where the
tibial plateau is tilted significantly,
there might be defect laterally, which
should be filled with either bone
Fig. 28.5 Tibial cut.
graft or augment (Fig. 28.6).
Following tibial resection, the extension and flexion gaps are assessed
using spacer blocks and laminar spreaders. Any discrepancy is noted.
In cases where the tibial slope
is anterior, generally the flexion
gap is larger than the extension
gap. Cases with recurvatum will
have extension gaps larger than
the flexion gap. Depending on the
situation, the distal cut is decided.
Distal femoral valgus angle is set
as per the preoperative plan. After
the distal cut is made, one must
confirm the amount of bone resec-
tion by measuring the cut surfaces.
Femoral rotation can be decided
based on epicondylar axis, white-
Fig. 28.6 Augmentation.
side line or tibial cut. We prefer
to use the tibial cut surface as the reference for deciding femoral rota-
tion. When significant mismatch between flexion and extension gap is
present, the femoral component may be upsized, taking care to avoid
overhang medio-laterally. Narrow femoral design may be used in such
cases. Appropriate box is prepared when posterior stabilized design is
used. We prefer to avoid cruciate retaining (CR) design in post HTO
knees due to unpredictable behavior of posterior cruciate ligament
(PCL) in these cases. Trial components are inserted and knee is taken
through range of motion. Avoid any flexion deformity or recurvatum.
Check the alignment, medio-lateral stability both in extension as well
as flexion; patellar tracking should also be checked. In cases where there
is significant patella infera, there are chances of patellar impingement
on tibial insert. This can be avoided using thinner patellar button and
placing it more proximally on patellar cut surface. We prefer to perform
lateral release when there is slightest evidence of tightness of retinacu-
lum or patellar maltracking. In this set of patients where there might
be previous scar on lateral side, raising flap is not advisable. Hence, we
use inside-out technique for lateral retinacular release. If knee is tight
laterally in extension, we prefer to perform pie crusting of IT band. In
rare instance where the medial ligament is stretched and knee cannot
be balanced, we use constrained implants.
Preparation of tibial surface is important for several reasons. The
quality of bone of the cut surface may not be good for cementing, espe-
cially laterally. In such cases, the surface may be prepared with a high
speed burr or tibial stem extension may be used. If the previous implant
is not coming in the way, it can be left in situ (Fig. 28.7). In case they
are interfering with proper sitting of tibial tray, they should be removed.
We remove staples using a small separate lateral incision directly over
the implant. If only small part of the tip is coming in the way of the
keel, it may be bent and implant negotiated. It is general tendency to
lateralize the tibial tray during preparation but in these cases the tibial
tray is best kept flush medially. This will allow routine implant to be
used in most of the cases.
A B
Fig. 28.7 (A, B): Implant in situ.
After the satisfactory trial, implants are cemented in place and the
wound closed in layers after infiltrating the arthrotomy edges with cocktail
for pain relief. We do not use drains.
Postoperative rehabilitation: Depending on the status of the
ligaments and balancing, rehabilitation protocol is individualized.
Most patients are made to stand on the same day of surgery with long
knee brace. Knee bending in bed and ankle pumps are also started
on the same day. Walking and stair climbing are started the next day.
Depending on the pain level, high sitting can be done on 2nd or 3rd
postoperative day. Patients are discharged on 4th postoperative day after
checking the status of the wound.
RESULTS
Controversy still exists regarding the results of total knee replacement after
failed tibial osteotomy. Literature is replete with the data which is contra-
dictory. Some suggesting no difference between post HTO and primary
knee replacement group, whereas others suggesting that converse is true.1
The differences in these series appear to be due to various factors. Failed
HTO group is a heterogenous group consisting of knees ranging from
those equaling primary knee to those with severe malalignment, ligament
laxity, patella infera, bone loss, tibial plateau tilting and shifting and soft tis-
sue scarring. Nevertheless, regardless of the results, the fact that stands out
in most of the studies is that conversion of a failed osteotomy to total knee
replacement is technically demanding, and several problems not generally
encountered in primary arthroplasty have to be solved. Soft tissue balancing
can indeed be taxing in these cases as the nature of the soft tissue problems
found in postosteotomy patients is entirely unpredictable.1
As far as the pain relief is concerned, prior HTO did not compromise
the result but some studies did report decreased range of motion following
knee replacement in prior HTO group.2,3 In many series, the rate of asso-
ciated procedure like lateral release was found to be higher than primary
knee replacement.2–4 Almost all the authors agreed to the fact that knee
replacement after failed tibial osteotomy is technically more demanding
than primary knees.
Since the question whether previous high tibial ostotomy can have any
deleterious effect on the outcome of total knee arthroplasty (TKA) or not
remains unanswered, it becomes imperative to find out what factors can
contribute to the poorer outcome. Based on the review of earlier series,
some surgeons had hypothesized that patella infera and significant coronal
plane deformity lead to more difficult knee arthroplasty with less satisfac-
tory results following HTO.5,6
Parvizi et al.4 in their study assessed subgroup of patients who underwent
bilateral TKA after a previous unilateral proximal tibial osteotomy. They
found that the rate of revision and prevalence of radiolucent lines were higher
in patients who were young heavy males with preoperative malalignment.
They argued that from the beginning, the patients who have had a previous
osteotomy were a highly selected population with an unfavorable demo-
graphic status. This is in view of the assumption that because of the surgical
selection, the majority of patients undergoing proximal tibial otsteotomy are
young, active and frequently heavy men who are deemed too young for TKA.
Many previous studies have suggested less satisfactory outcomes from

TKA after HTO than are to be expected from primary TKA.7–9 Other
authors have not shown any such association, finding similar results from
TKA after HTO and from primary TKA.5,10–12 All of these studies fol-
lowed patients for relatively short period after TKA (2–7 years after TKA).
In some studies, the small number of patients in the HTO group would be
insufficient to demonstrate anything other than very dramatic differences
between groups. Several of these studies also involved multiple prostheses
and surgeons.
In a significant case match study, Haslam et al.1 compared 51 post HTO
arthroplasties with primary knee arthroplasties. The patients were matched
according to length of the follow-up, age, sex, prosthetic design and surgeon.
The average follow-up was 12.6 years with minimum length of follow-up
being 5 years. They found higher incidence of poor results, significantly
reduced flexion and higher reoperation rates. Important finding was that
most failures occurred 6 years or more after the TKA. This strongly suggests
that studies with shorter follow-up should be interpreted with caution. Table
28.1 shows the results of comparable studies.
Table 28.1 Comparative results of various studies: TKA in post HTO
Authors Journal Year No.of Follow HTO Control No. of No. of Infection Infection
patients up group group failure failure in in the in the
(years) score score in HTO control HTO control
group group group group
Katz et JBJSA 1987 21 2.9 86 93 2 0

al.8
Amendola J Arthr 1989 42 1.5 8.6 89 0 0 0 0

et al.12
Bergenudd J Arthr 1997 14 6 79 81 3 3 1 0

et al.10
Toksvig- JBJSA 1998 40 10 0 4 1 0 0

Larsen et
al.5
Nizard et J Arthr 1998 63 4.6 79 83 1 0 2 0

al.9
Meding et JBJSA 2000 39 8.7 81 83.9 1 0 0 0

al.6
Hadda and J Arthr 2000 50 6.2 87 89 2 3 1 2

bently
Haslam et J Arthr 2007 40 12.6 79 80 11 4 3 0

al.1
HTO, high tibial osteotomy.

While modern and more precise method of osteotomies may eliminate

some of the problems seen with conventional osteotomies, it is equally pos-
sible that they may worsen the situation if much hardware is used. In view
of the available data, we feel that young and active patients still remain can-
didates for HTO but the indications are becoming more exacting. The use
of tibial osteotomy as a prelude to knee arthroplasty should be undertaken
with caution and only in cases ideally suited for osteotomy. This is espe-
cially true in light of the excellent results shown by Diduch et al. in young
patients undergoing total knee replacement. If due to age and activity, the
patient must be offered HTO, he should be counseled that whenever the
HTO fails, subsequent knee replacement is more difficult and might per-
form less well or be prone for early failure.
REFERENCES
1. Haslam P, Armstrong M, Geutjens G, et al. Total knee Arthroplasty after failed high tibial
osteotomy. J Arthroplasty 2007;22(2).
2. Scuderi GR, Windsor RE, Insall JN. Observations on patellar height after proximal
tibial osteotomy. J Bone Joint Surg Am 1989;71:245.
3. Nagel A, Insall JN, Scuderi GR. Proximal tibial osteotomy: a subjective outcome study.
J Bone Joint Surg Am 1996;78:1353.
4. Parvizi J, Hanssen A, Spangehl M. Total knee arthroplasty following proximal tibial
osteotomy: risk factor for failure. J Bone Joint Surg 2004;86A:474.
5. Toksvig-Larsen S, Soren G, et al. Fixation of the tibial component after high tibial oste-
otomy: a matched stereometric study. J Bone Joint Surg Br 1998;80:295.
6. Meding J, Keating M, Ritter M, et al. Total knee arthroplasty after failed high tibial
osteotomy. J Bone and Joint Surg 2000;82-A:1252.
7. Windsor RE, Insall JN, Vince KG. Technical considerations of total knee arthroplasty
after proximal tibial osteotomy. J Bone Joint Surg 1988;70A:547.
8. Katz MM, Hungerford DS, Krackow KA. Results of total knee arthroplasty after failed
proximal tibial osteotomy for osteoarthritis. J Bone and Joint Surg 1987;69-A:225–33.
9. Nizard RS, Cardinne L, Bizot P, et al. TKA after failed HTO. J Arthroplasty 1998;13:847.
10. Bergenudd H, Sahlstrom A, Sanzen L. TKA after failed HTO. J Arthroplasty 1997;12:635.
11. Staeheli JW, Cass JR and Morrey BF. Condylar total knee replacement after failed proxi-
mal tibial osteotomy. J Bone and Joint Surg 1987;69-A:28–31.
12. Amendola A, Rorabeck CH, Bourne RB, Apyan PM. Total knee arthroplasty, following
high tibial osteotomy for osteoarthritis. J Arthroplasty 1989;4:S11:13.
13. Jackson M, Sarangi PP, Newman JH. Revision total knee arthroplasty. J Arthroplasty
1994;9(5):539–42.
PART 4
Recent Advances in the

Hip and Knee
Arthroplasty
Chapters
29. Trabecular Metal 327
30. Recent Advances in Short Stem Designs 341
31. Hi-Flex Knee Design 350
Chapter 29
Trabecular Metal
Pichai Suryanarayan, Ashok Kumar
The ideal method for lasting fixation of the prosthetic implants is still a
subject of discussion. Various options exist with varying degrees of success.
Component fixation with cement is a very cost-effective viable option.
This is a highly technique-sensitive method with not very consistent results
in all hands.1–3
Noncemented fixation of endoprosthesis has gained broad acceptance,
especially in the hips. Incidence of noncemented fixation in the knees
though is much less. Reported long-term results with uncemented recon-
structions of the acetabulum have been very satisfying with survival as
high as 95% at 15 years.4–6 These results are independent of demographic
factors, reasons for revisions and underlying diagnosis. The published
data from the various registries also support this. This biologic fixation
is obtained by the in-growth or on-growth of bone onto the specially
treated surface of the component that is in contact with the bone. The
various methods being hydroxyapatite coating, grit-blasted surface, porous
coating, fiber mesh, etc. In most situations, this integration happens in
10–12 weeks. The minimum requirements for this to happen within this
timeframe are:
1. Mechanical stability of the implanted component.
2. Adequate contact with vascular host bone. Average recommended
coverage is a minimum 65–70% of the surface area.
Any shortcomings on these may lessen the chances of the cup integra-
tion. We then face a race between cup integration and the component
failure (tilt/migration). Achieving a primary stable fit is a challenge in the
presence of bone deficiencies like post-traumatic arthritis, arthritis due
to developmental dysplasia of the hip, revisions, etc. Reports from many
published series seem to suggest a direct correlation between the degree
of acetabular bone loss and the failure of the uncemented cups in revision
hip surgery.7,8 Common approaches to treatment in these situations are:
1. Allograft reconstruction of the defect
2. Morsellised graft with rings and support cages
3. Bilobed cups, oblong cups and custom devices
328 Part 4 | Recent Advances in the Hip and Knee Arthroplasty
Though these are good reconstructive alternatives, overall outcomes

have not been very satisfactory. Results with bulk allograft seem depen-
dent on the size of the defect needing graft, with a failure rate between
6% and 44%.9,10 Failure rates with the use of rings and antiprotrusio cages
and allografts too are around 14% in the medium term.11,12 However, the
reported experience seems better in the data published by some European
centers.13 In addition, with larger deficiencies, it is a technical challenge
to get good primary stability. Reports with less-than-optimal results with
the various treatment options for major deficiencies, hence, have generated
interest in the development and use of alternate materials with better bio-
logical and mechanical properties.
TANTALUM
Elemental Tantalum (Ta) is no. 73 on the table. The name is derived from
Tantalus, a Greek mythological character. This is a transitional metal that
is highly corrosion resistant even to strong acids. Tantalum is classified in
the refractory metal groups and is commonly used as a minor component
in various alloys. Chemically too it is very inert.
Tantalum exists in two crystalline phases, alpha and beta. The alpha
phase is relatively ductile and soft. The beta phase is hard and brittle. The
beta phase can be converted to alpha phase on heating to 750°C. The bulk
tantalum is usually in the alpha phase. Following processing and conversion
to thin films by chemical vapor deposition or electro chemical deposition,
it converts into the beta form.
The highly elastic and ductile properties together with the toughness
make it an ideal metal of choice for implant manufacture. These salient
properties are most suitable to avoid or considerably minimize the stress
shielding, which is an issue with the other commonly used materials like
Co–Cr, titanium, etc. Being nonferrous, its implantation also does not con-
traindicate the performance of MRI in these patients.
MANUFACTURING PROCESS
Trabecular metal (TM), unlike the other alloys or metal, is neither an
elemental metal nor an alloy. It is essentially a reticulated carbon network
coated with elemental tantalum. Since the micro architecture resembles the
trabeculae of the bone, it goes with the name trabecular metal.
Trabecular Metal 329
The core of this material is a reticulated carbon network with uni-

formly interconnected pores. This macroscopically resembles the structure
of a sponge. Commercially pure tantalum is deposited over this exoskeleton
of carbon. This is done by a process called chemical vapor deposition, in a
special chamber (Fig. 29.1).
Solid Tantalum Heat
Tantalum Gas
Carbon Precursor Vitreos Carbon

with solid
Tantalum deposit
Heat
Vacuum
Fig. 29.1 (A) Vapor deposition of tantalum on the vitreous carbon matrix (with permission,
Zimmer, Inc., Warsaw, IN). (B) Trabecular metal (with permission, Zimmer, Inc., Warsaw, IN).
The thickness of the coating can be controlled during the manufactur-

ing process. Unlike the implants made from other metals, the components
are not machined to shape and size but a core of the reticulated vitreous
carbon network is cut to the desired shape and size over which the tantalum
is deposited. Thus, by controlling the thickness of the tantalum layer, one
can control the strength of the desired component during manufacture. This
unique manufacturing process thus allows the fabrication of components in
any desired shape and size, without the loss of any of its structural properties.
SALIENT FEATURES OF TRABECULAR METAL

Certain physical and metallurgical features make the TM distinctly differ-
ent when compared to the other materials like titanium or stainless steel.
Osteophilic micro texture of the surface, bio inertness, toughness to resist
cyclical loading, low elastic modulus of the material are some of the desir-
able material features for a lasting fixation of the noncemented devices.
These desirable features, namely, high friction surfaces, decreased micro
motion, high resistance to torque forces, rapid integration are being incor-
porated on to the implant surfaces also by other technologies and materials.
Super textured asperity topography (STAT) is another method adopted in
the manufacture of GriptionTM implants. TritaniumTM (commercially pure
titanium matrix) IntegripTM, etc. are the various other materials available
today with these enhanced properties for rapid bone integration.
Table 29.1 Elastic modulus of pertinent components with permission, Zimmer, Inc.,
Warsaw, IN)
Elastic 1 2 3.1 110 210
Modulus (Gpa)
Material Poly Cement Tantalum Titanuim Co–Cr
1. Elastic modulus (stiffness)14, 15: Implants made of Co–Cr; titanium etc

have a modulus of elasticity significantly higher than that of the bone.
The elastic modulus of TM approaches that of the bone, thus making it
considerably less stiff (Table 29.1).
2. Ductility: The ductile property of elemental tantalum is also reflected
in the TM. The high fatigue strength seen in in vitro testing is attributed
to the porous interconnected three-dimensional architecture of the TM.
Hence, when this material is subject to high physical forces in various
modes like compression, tension or torsion, it deforms plastically rather
than breaking (Fig. 29.2).
TM being much less stiff compared to the other metals, it is postulated
that the resultant stress shielding with TM is much less. Finite element
Fig. 29.2 Deformation of a tantalum cone under various

loading pattern (with permission, Zimmer, Inc., Warsaw, IN)
analysis studies seem to suggest that stress transfer with TM cups is more
physiological and is similar to the cemented cups. It is well known that
stress shielding is a cause for concern as we look at long term follow-ups,
since this results in bone loss, propensity to periprosthetic fractures and
difficulty with future revisions.
3. Porosity: Sectional architecture of TM is essentially an array of inter-
connected pores almost resembling the architecture of trabecularbone.
This structural characteristic gives it a volume porosity of 75–80%
(Fig. 29.3).
A B
Fig. 29.3 (A) Structure of bone (with permission, Zimmer, Inc., Warsaw, IN). (B) Structure
of trabecular metal (with permission, Zimmer, Inc., Warsaw, IN).
This is thrice that of the other porous materials in use. Laboratory studies
show that pore sizes of around 300 mcm (micrometer) of the porous bio-
material scaffolds, induces good osteogenesis and formation of neo capillar-
ies.16 The sectional pore size of TM ranges between 270 and 430 mcm.17
This structural characteristic enables good biologic in-growth of bone
and capillaries.
4. Coefficient of friction18,19: The frictional coefficient of this material
is 0.98. This is much higher than that of the other porous surfaces and
materials (Table 29.2). This high interfacial friction between bone and
TM enables a solid fixation of the implants to the bone with enhanced
initial stability of the fixation construct.
Table 29.2 Frictional coefficients of various materials (with permission, Zimmer, Inc.,
Warsaw, IN)
These unique properties of this material, namely, the high porosity, low
elastic modulus and high coefficient of friction and the feasibility to manu-
facture various components and augments of various shapes and sizes, offer
an additional reconstructive option in difficult reconstructions, especially
revision surgeries. Independent reports from various centers have shown
rapid bone integration and in-growth.
Despite the appropriate preparation and a primary fit, interstitial gaps
between the implant and the host bone are inevitable. It is seen that these
gaps are filled with bone in-growth to varying degrees depending on the
depth of the defect, bone quality and construct stability. Primary stability,
the pattern of stress transfer across the interphase, the biological properties
of the material are some of the factors that influence the volume and rate
of this neo bone formation. Gruen et al.20 in their studies have shown sig-
nificantly better volume of interstitial gap fill in acetabulum with the TM
cups when compared to the conventional titanium cups. Also in long-term
observations, no new radiolucencies were observed. The osteophilic nature
of the TM surface, better load transfer due to the low modulus of elasticity
and the porous structure facilitating better bone and vascular in-growth
explain the rapid and more robust tissue response with the TM.21,16 In addi-
tion, the better interfacial frictional contact enables a better load transfer
and implant stability, factors that are crucial to bone in-growth.22,17
CLINICAL APPLICATIONS
The debate on the ideal fixation method still continues. Cementless fixa-
tion of endoprosthesis has given consistent good results. The minimum
prerequisites for a successful outcome are well defined, namely, primary
press fit, adequate host bone contact,good bone quality and stability of
the construct. Most of the developments have been focused on attempts
at improving the surface characteristics, alternate materials and coating or
texturing the contact surfaces to stimulate bone in-growth.
However, poor initial stability and deficient host bone contact, espe-
cially in the areas of stress transfer and weight bearing, lead to failure of
integration and eventual failure of the construct. The limitations for the
success of these devices are:
1. Less-than-optimal bone quality.
2. Structural defects in the bone bed necessitating complex reconstruc-
tive methods and restoration of the defect with the use of structural
grafts without which stable fixation of the device is difficult.
Failures of revascularization have led to the collapse and failure in the long
term when bulk grafts have been used. Use of support rings and cages in
major bone defects also have shown higher failure rate due to migration, loos-
ening and fatigue fractures of the device. This is because they are nonintegrat-
ing devices depending mainly on the strength of the screws for their fixation.
RATIONALE OF TM RECONSTRUCTIONS
The development of this alternate biomaterial was based on the analysis
of the reasons for failure of the uncemented devices in revision surgery
and also the less-than-optimal results seen with the alternate options of
reconstruction employed in the more severe defects. Notable issues were
difficulty in achieving primary stability, sectoral bone defects, difficulty in
optimizing bone contact for integration and bone in-growth leading to
failure of the construct.
The revision TM shell was the first prototype devised and used in this
clinical setting. The shell is a totally porous structure with only a periph-
eral ring on the margin. Since the liner is cemented into the shell, the
elastic modulus of the composite is still lower than the stiff titanium shells.
This induces better bone in-growth and minimizes the stress shielding.
The potential benefits of cementing the liner into the porous TM shell
are as follows.
1. It unitizes the assembly; thereby acts like a monobloc device, eliminating
the issue of backside wear.
2. One can independently dial in the version of the shell and liner, based on
the clinical situation and thereby maximizing bone coverage and contact
between the bone and the cup.
3. This also allows the placement of screws in extreme angles and directions,
hitherto not possible with the other titanium shells.
4. The feasibility to create and customize additional fixation holes in the
porous shell with a 4 mm high-speed drill is a great advantage. This pos-
sibility allows secondary fixation with additional holes in any quadrant as
the situation may demand, thus maximizing the stability of the shell and
increasing the spectrum of cases amenable to the reconstructions.23
5. The availability of augments made of the same metal is an added advan-
tage, which helps in rebuilding the various defects encountered.24,25 These
can be positioned in any deficient area to support the shell.
Certain features differentiate these revision shells from the primary
shells. The commercially available primary shells with modular locking

mechanism for the liner are essentially titanium shells with a coating of
TM. Their mechanical properties are very different. Being rigid, their
elastic modulus is high and the behavior is closer to the regular shells.
They do not possess the characteristics of a pure tantalum shell like the
revision shell or augment devices.
TM devices thus offer an additional option in these difficult and com-
plex situations. The advantages being as follows.
1. The physical features, namely, the low elastic modulus, the highly
porous structure and the inert tantalum surface are conducive for rapid
bone integration.26
2. Since the material is available as augments in various shapes and sizes,
it is possible to use them as a stand-alone substitute for bulk allograft in
major reconstructions. They provide mechanical support to the shell in
the deficient area and also undergo biological integration to the bone,
leading to permanent integration. Unlike the bilobed cups and oblong
cups, these augments give the flexibility to position them anywhere,
so long as there is some host bone to fix. This obviates the need for
allograft and the concerns associated with their use.
3. The published data on the medium and a few long-term results have
been very positive and encouraging.
4. The high coefficient of friction offers a good stable fit in the presence
of compromised bone enabling rapid bone in-growth and integration.
5. The experience to date shows that even with only 45–50% of available
bleeding host bone surface, predictable in-growth along with secondary
stabilization and integration is seen with TM reconstructions.
6. Lewallen et al.24,27 have reported favorable outcomes with the TM
device in extreme acetabular deficiency and pelvic discontinuity and
poor supportive bone quality where obtaining stability of the fixation
is a challenge. They described a new fixation technique, ‘the cup cage
construct.’ This involves implantation of the revision shell in contact
with the residual viable bone and an inset acetabular cage into the shell.
This enables fixation of the cage into the ileum and ischium in the
usual manner to obtain stability. The cage acts as an added temporary
osteosynthetic device during the time the TM shell gets integrated to
the host bone. The progressive integration of the TM cup over time
minimizes the stress on the cage, thus providing a long-term biological
solution and fixation.
TIPS AND TRICKS IN THE USE OF TM DEVICES

1. TM surfaces seem to attract intense osteoblastic and fibroblastic reac-
tion. Care must be taken to avoid direct exposure of the perineural
structures to the surfaces of TM, to avoid the danger of scar entrapment.
2. When using a TM shell in conjunction with augments, it is advocated
that the two components are unitized with a layer of bone cement.
This helps in better stability and also minimizes fretting metal debris.
3. In view of the porous structure, one can actually create additional
screw holes, with high-speed metal burrs to augment fixation in the
available bone. This possibility is unique, which is not feasible with
any of the other devices.
ACETABULAR DEFECTS AND USE OF TM SHELLS AND

AUGMENTS
Most contained defects and mild-to-moderate bone deficiency situations
are well amenable to revisions with the standard porous shells. When the
nature and size of the defects make primary stability unachievable, TM
augments can be used to optimize the mechanical support and stability
to the shell. Meneghini, Lewallen28 and others from the Mayo clinic have
described and classified the patterns of the bone defect reconstructions
with the TM augments.
Type 1 defects (superior and superolateral deficiency)29: The
augment is placed superiorly to support the shell and minimize proxi-
mal lateral migration. This construct is akin to the flying buttress graft
described for superior deficiencies (Fig. 29.4).
Type 2 and Type 3 defects: These defects correspond to the Paprosky
Type 3A and 3B defects. The use of augments in these situations is similar
to the use of oblong cups or the bilobed cups. The construct in addition
also helps in restoring the center of rotation of the hip. The augments can
be dialed into any position based on the nature of the defect, so that the
best bone contact is possible (Figs 29.5 and 29.6).
Column Augments
Posterior and posterosuperior deficiencies almost always have been treated
with the use of bulk grafts fit in the figure 7 shape from the femoral heads.
This lends the structural support for further reconstruction that can then be
completed either with the uncemented shells or with the use of the various
B C
Fig. 29.4 (A) Type 1 acetabular deficiency in the superior sector. (B) Reconstruction with
the superior augments. (C) Postoperative X-ray with restoration of the hip center and
integration of the components.
rings and cages. TM column augments perform the same function and are
designed as a stand-alone substitute for the posterior column deficiency.
The chosen augment is fixed to the posterosuperior ilium which then gives
a column support for the TM revision shell (Fig. 29.7).
Extreme bone defects, poor bone, pelvic discontinuity are situations
where a cup cage construct is a useful method and a bailout option.30
A B
Fig. 29.5 (A) Type 3 acetabular deficiency following acetabular fracture. (B) Reconstruction
with superior augments.
A B
Fig. 29.6 (A) Type 3 acetabular deficiency with posterior column deficiency. (B)
Reconstruction with high hip center and inferiorly placed augment to optimize bone
contact.
A B
Fig. 29.7 (A) Failure of the cage with total posterior column deficiency. (B) Recon-
struction with a buttress augment to restore the posterior column.
USE OF TM IN KNEE ARTHROPLASTY

Expanded applications for the use of TM in knee joint reconstructions are
also gaining increasing acceptance among the surgeons. Notable examples are
the noncemented monoblock tibial components. In addition to more pre-
dictable fixation, this is also a solution to overcome the issues of backside wear
and the locking mechanism issues of the modular devices. TM augments31 are
available in the form of cones that help overcome the large tibial and femoral
defectsin revision knee surgery. They obviate the need for large grafts and
provide a structural support to enable stable fixation of the knee components.
This also facilitates the restoration of the joint kinematics, when faced with
large metaphysealdeficiencies, by enabling a good biological integration and
stable base over the residual bone over which rest of the reconstruction can
be built up. The published data with the use of TM has been very encourag-
ing and this has led to the progressive expansion of the indications for its use,
namely, reconstruction of the patella and the extensor mechanism in revi-
sion knee surgery. Various authors have reported techniques for the use TM
devices when faced with significant bone defects (Fig. 29.8).32
A B
Fig. 29.8 (A) Uncontained medial bone defect of tibia. (B) Defect reconstruction with
trabecular cone. (Images courtesy Dr. Ashok Rajagopal, Medanta Medicity, New Delhi)
Schildhauer et al.33 have reported on the bacterophobic properties

of Tantalum in vitro studies. Bacterial adhesion studies of Staphylococcus
on various metal surfaces including tantalum, showed the Staphylococcus
adhesion to be the lowest for tantalum. Since the rate of clinically mani-
fest infections is related to bacterial adhesions over implant surfaces, it is
believed that tantalum as a material may be more suitable when compared
to the other metals in use. Probably there is a greater role for TM devices,
in the staged reconstructions for septic joints, though this needs clinical
validation. Some recently published reports on early clinical results and in
vitro studies have shown decreased reinfection rates with TM implants.34–36
This has been attributed to the nano structure of the trabecular devices,
the conducive pore size that has an inhibitive effect on biofilm formation.
The osteogenesis and the neovascularization noticed in the vicinity of
the pores have encouraged its use as TM rods in avascular necrosis. Modest
outcomes have been reported with this technique. Long-term results are
still awaited.
The long-term results with the TM devices have established them as
a very viable alternative. The enhanced osteo-integrating properties, the
better metallurgical attributes, namely, the high coefficient of friction, low
modulus of elasticity, etc. make them attractive alternatives and an added
tool in the more challenging revision situations.
REFERENCES
1. Klapach AS, Callaghan JJ, Goetz DD, Olejniczak JP, Johnston RC. Charnley total hip
arthroplasty with use of improved cementing techniques: a minimum twenty year follow-
up study. J Bone Joint Surg Am 2001;83-A(12):1840–48.
2. McCaskie AW, Gregg PJ. Femoral cementing technique: current trends and future devel-
opments. J Bone Joint Surg Br 1994;76(2):176–77.
3. Nedungayil SK, Mehendele S, Gheduzzi S, Learmonth ID. Femoral cementing techniques:
Current trends in the UK. Ann R Coll Surg Engl 2006;88(2):127–30.
4. Della Valle CJ, Berger RA, Rosenberg AG, et al. Cementless acetabular reconstruction in
revision total hip arthroplasty. Clin Orthop Relat Res 2004;420:96–100.
5. Hallstrom BR, Golladay GJ, Vittetoe DA, et al. Cementless acetabular revision with the
Harris-Galante porous prosthesis; results after a minimum of ten years of follow-up. J Bone
Joint Surg [Am] 2004;86:1007–11.
6. Templeton JE, Callaghan JJ, Goetz DD, et al. Revision of a cemented acetabular compo-
nent to a Cementless acetabular component: a ten to fourteen-year follow-up study. J Bone
Joint Surg [Am] 2001;83:1706–11.
7. Paprosky WG, Burnett RS. Assessment and classification of bone stock deficiency in revi-
sion total hip arthroplasty. Am J Orthop 2001;31:459–64.
8. Saleh KJ, Jarosynski G, Woodgate I, et al. Revision total hip arthroplasty with the use
structural allograft and reconstruction ring: a case series with the ten year average follow-
up. J Arthroplasty 2000;15:951–58.
9. Garbuz DS, Penner MJ. Role and results of segmental allografts for acetabular segmental
bone deficiency. Orthop Clin North Am 1998;29:263–75.
10. Parosky WG, Magnus RE. Principles of bone grafting in revision total hip arthroplasty:
acetabular technique. Clin Orthop Relat Res 1994;(298):147–55.
11. Udomkiat P, Dorr LD,Won YY, et al. Technical factors for success with metal ring acetab-
ular reconstruction. J Arthroplasty 2001;16:961–69.
12. Schatzker J,Wong MK. Acetabular revision: the role of rings and cages. Clin Orthop Relate
Res 1999;369:187–97.
13. Winter E, Piert M, Volkmann R, et al. Allogeneic cancellous bone graft and a Burch-
Scneider ring for acetabular reconstruction in revision hip arthroplasty. J Bone Joint Surg
[Am] 2001;83:862–67.
14. Corces A, Garcia M. Metallic Alloys. eMedicine orthopedic surgery. Available at: http://
emedicine.medscape.com/article/1230554-overview. Updated on Feb 3, 2010.
15. Bobyn JD, Tanzer M, Krygier JJ, Lewallen DG, Hanssen AD, Lewis RJ. Clinical validation
of a structural porous tantalum biomaterial for adult reconstruction. Annual Meeting of
the American Academy of Orthopaedic Surgeons edition. San Francisco, CA, 2004.
16. Karageorgiou V, Kaplan D. Porosity of 3D biomaterial scaffolds and osteogenesis.
Biomaterials 2005;26(27):5474–91.
17. Bobyn JD, Hacking SA, Chan SP, Toh KK, Krygier JJ, Tanzer M. Characterization of a
new porous tantalum biomaterial forreconstructive orthopaedics. Annual Meeting of the
American Academy of Orthopaedic Surgeons edition. Anaheim, CA, 1999.
18. Fitzpatrick D, Ahn P, Brown T, et al. Friction coefficients of porous tantalum and cancel-
lous & cortical bone. 21st Annual American Society of Biomechanics, Clemson, SC, 1997
19. Black J. Biological performance of tantalum. Clin Materials 1994;16:167–73.
20. Gruen TA, Poggie RA, Lewallen DG, Hanssen AD, Lewis RJ, O’Keefe TJ, et al.
Radiographic evaluation of a monoblock acetabular component: a multicenter study with
2- to 5-year results. J Arthroplasty 2005; 20(3):369–78.
21. Macheras G, Kateros K, Kostakos A, Koutsostathis S, Danomaras D, Papagelopoulos PJ.
Eight- to ten-year clinical and radiographic outcome of a porous tantalum monoblock
acetabular component. J Arthroplasty 2009; 24(5):705–09.
22. Zhang Y, Ahn PB, Fitzpatrick DC, Heiner A, Poggie RA, Brown TD. Interfacial fric-
tional behavior: cancellous bone, cortical bone, and a novel porous tantalum biomaterial.
J Musculoskeletal Res 1999;3(4):245–51.
23. Bobyn JD, Poggie RA, Krygier JJ, et al. Clinical validation of a structural porous tantalum
biomaterial for adult reconstruction. J Bone Joint Surg [Am] 2004;86[Suppl 2]:123–29.
24. Nehme A, Lewallen DG, Hanssen AD. Modular porous metal augments for treat-
ment of severe acetabular bone loss during revision hip arthroplasty. Clin Orthop
2004;429:201–08.
25. Hockman DE, Ammeen D, Engh GA. Augments and allografts in revision total knee
arthroplasty: usage and outcome using one modular revision prosthesis. J Arthroplasty
2005;20:35–41.
26. Bobyn JD, Stackpool G, Toh K-K, et al. Bone ingrowth characteristics and interface
mechanics of a new porous tantalum biomaterial. J Bone Joint Surg 1999;81-B;907–14.
27. Berry DJ, Lewallen DG, Hanssen AD, et al. Pelvic discontinuity in revision total hip
arthroplasty. J Bone Joint Surg [Am]. 1999;81:1692–1702.
28. Lewallen DG, Meneghini RM, Mardones RM, et al. Revision hip arthroplasty with
porous tantalum augments and acetabular shell. Proceedings of the 2006 Annual Meeting
of the American Academy of Orthopaedic Surgeons (AAOS).
29. Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgi-
cal reconstruction in revision arthroplasty: a 6-year follow-up evaluation. J Arthroplasty
1994;9:33–4.
30. Abolghasemian M, Tangsataporn S, Sternheim A, et al. Combined trabecular metal ace-
tabular shell and augment for acetabular revision with substantial bone loss - a midterm
review. Bone Joint J 2013;95-B:166–172.
31. Lachiewicz PF, Bolognesi MP, Henderson RA, Soileau ES, Vail TP. Can tantalum
cones provide fixation in complex revision knee arthroplasty? Clin Orthop Relat Res
2012;470(1):199–204.
32. Tigani D1, Trentani P, Trentani F, Andreoli I, Sabbioni G, Del Piccolo N. Trabecular metal
patella in total knee arthroplasty with patella bone deficiency. Knee. 2009;16(1):46–9.
33. Schildhauer TA, Robie B, Muhr G, et al. Bacterial adherence to tantalum versus com-
monly used orthopedic metallic implant materials. J Orthop Trauma 2006;20:476–83.
34. Del Gaizo DJ, Kancherla V, Sporer SM, Paprosky WG. Tantalum augments for
Paprosky IIIA defects remain stable at midterm followup. Clin Orthop Relat Res
2012;470(2):395–401.
35. Howard JL, Kudera J, Lewallen DG, Hanssen AD. Early results of the use of tantalum fem-
oral cones for revision total knee arthroplasty. J Bone Joint Surg Am 2011;93(5):4478–84.
36. Lachiewicz PF, Bolognesi MP, Henderson RA, Soileau ES, Vail TP. Can tantalum
cones provide fixation in complex revision knee arthroplasty? Clin Orthop Relat Res
2012;470(1):199–204.
Chapter 30
Recent Advances in
Short Stem Designs
S.K.S. Marya, Sumeet Rastogi
INTRODUCTION
Increasingly, more young and active patients with end stage hip disease are
seeking hip replacement surgery. This change in the demographic pro-
file of the patients who have a greater functional demand and expect to
return to active lifestyle has put an increased demand on the orthopaedic
surgeons to conduct so-called bone-preserving surgeries that maximize
preservation of bone stock by retaining the femoral head and neck and
minimize diaphyseal violation. This combined with minimally invasive
technique and keeping in mind the higher expected revision surgery
rates in this age group makes short stems a very attractive alternative to
conventional stems.
Short stems are stems for total hip arthroplasty (THA) that are anchored
in the metaphysis and the proximal part of the diaphysis and are shorter
than the classic standard stems.
Bone and soft tissues sparing in approach, they promote maximum
physiological loading of the proximal femur thus preventing stress shielding.
Active bone in-growth into the structured surface of stem provides both
early and sustained bony fixation.
Short stem hips come in a number of designs and design philosophies,
although most are with titanium and hydroxyapatite coatings.
RATIONALE
Several advantages have been attributed in favor of short stems over stan-
dard stems. They include the following.
% Preserve the proximal femoral bone stock
% Decrease stress shielding
% Decrease in the thigh pain rate
% Easy minimally invasive surgical procedures
% Improve long-term stem survival

% Ease surgical revision
CLASSIFICATION
With so many short stems with significant variation in geometry and phi-
losophy in the market, a simplified classification system was proposed by
The Joint Implant Surgery and Research Foundation (JISRF).1 It basically
classifies short stems into four groups:
1. Head stabilized
A. Hip resurfacing
B. Mid-head resection stem
2. Neck stabilized
A. Short curved stems
B. Short lateral engaging stem
C. Neck plugs or neck only
3. Metaphyseal stabilized
A. Taper stems
B. Bulky/fit and fill stems
4. Conventional metaphyseal/diaphyseal stabilized
Research has been directed towards creating a modern femoral implant
that is anatomical in shape, preserves healthy femoral bone during implanta-
tion, loads the neck and metaphyses in a near physiological manner and cre-
ates a biomechanically favorable offset while minimizing soft tissue handling.
BIOMECHANICAL ADVANTAGES
Studies have demonstrated that neck preservation offers significant implant
stability and allows for more accurate reproduction of hip biomechanics and
geometry. The tough cortical bone of the femoral neck and the metaphy-
seal cancellous bone facilitate good proximal primary fixation of prostheses.
Studies have also shown that retaining the femoral neck improves com-
ponent stability by offering greater rotational strength and stiffness, better
resistance to varus–valgus stress and subsidence.2,3 Other studies have found
that neck-retaining designs have lower rotational interface micro-motion
and slippage at the bone–implant interface.4 Experimental data have shown
that the torsional load-bearing capacity of the proximal femur is signifi-
cantly reduced by resecting the femoral neck below the mid-neck level.5
Recent Advances in Short Stem Designs 343
BONE CONSERVATION
DEXA studies evaluating the influence of femoral stem length have shown
that progressive shortening of the stem produces more proximal loading,
which preserves metaphyseal bone stock and increases bone mineral den-
sity (BMD) in the medial zones.2
NECK STABILIZING STEMS

This is one of the fastest growing market segments for short stems.
Historically, femoral neck retention was advocated by Freeman, Townley,
Whiteside and Pipino. Only Pipino advocated a short, curved neck-
sparing stem. The ring of cortical bone saved in the neck-sparing stem
has significant biomechanical advantage. Pipino referred to this as a
‘tension band.’ Freeman, Townley and Whiteside all advocated saving
the neck with the use of standard length stems that engaged the neck,
metaphysis and diaphysis. For example, CFP stem by Link, Promise stem
by Permedica, etc.
PART OF THE NECK STABILIZED FAMILY PLUGS

Devices that are designed to sit in the femoral neck and have minimal
metaphyseal engagement. For example, Silent stem by DePuy, Spiron
femoral neck prosthesis by Fa. K-implant, Garbsen, Germany.
METAPHYSEAL STABILIZING STEMS

There is a long history of using short metaphyseal stems that include ana-
tomical, straight and tapered style stems. Variable results have been seen
often depending on implant design, surgical technique, bone quality and
patient related activities. For example, Biomet microplasty stem by Biomet,
Trilock by DePuy.
Short stems can also be categorized as those with a collar, those
without, straight or curved stems, or those that are shortened versions
of stems already in the market. The device with the longest track record
(98.2% survival at 10 years) is the Mayo stem launched in 1984.6 This is a
neck-retaining device, which has a proximal wide trapezoid cross-section
for multi point contact within the femoral cortical bone; the reduced
diaphyseal segment is required only for varus–valgus alignment. The tip
touches the lateral cortex, which is at risk of perforation during insertion.

The original grit blasted finish has been superseded by a hydroxyapatite
coating. The stem shape is based on a curved trapezoidal design that is
intrinsically stable within the cylindrical femur. Subsequently, two new
implants based on the same principle were introduced, the Nanos stem
(Plus Orthopedics, Switzerland) and Metha stem (BBraun, Germany).
They grossly reproduced the shape of Mayo stem with minor varia-
tions, most notably, major neck preservation. While the Nanos presents a
rounded cross-section, Metha retained the trapezoid shape.
Of the metaphyseal stabilizing devices, the Metha short hip stem from
BBraun has a similar geometry to the Aida short stem. The proxima short
stem hip from Depuy (Fig. 30.1) has a proximal fit and fill geometry, with
a large lateral trochanteric flare than other stems, but is shorter than most
others, so care needs to be taken with varus/valgus positioning. To prevent
damage to greater trochanter–abductor complex and Gluteus medius mus-
cle, a ‘Round the corner’ technique
had been used for broaching the
femoral canal. In this technique, the
broaching and final implant inser-
tion are done with a slight curved
movement of the insertion handle
(Figs 30.2 and 30.3). The Fitmore
from Zimmer has a triple taper
design and proximal Ti-Plasma coat-
ing enables secure press-fit, while the
trapezoidal cross-section provides for
rotational stability.
A variety of neck-stabilizing hip
plugs, also called neck arthroplasty
device by some surgeons, are now
available. With minimal metaphy-
seal engagement, they are purely Fig. 30.1 Proxima hip.
designed to sit in the femoral neck.
The Spiron™ Hip has a conical, self-cutting screw that is inserted
without cement into the prepared subcapital femoral neck (Fig. 30.4).
The CUT™ Stem implant is made from a cobalt–chromium–molyb-
denum (CoCrMo) alloy and has a macroporous structure. The stem is
curved at the distal tip designed to rest against the lateral cortex of the
femur (Fig. 30.5).
A B
C D
E F
Fig. 30.2 (A–F) Intraoperative steps of ‘round the corner technique.’
A B
Fig. 30.3 (A, B) Preoperative and postoperative X-ray of B/L proxima hip replacement.
A B
Fig. 30.4 (A, B) Spiron™ hip.
The TSI™ Neck Implant is

designed to load the medial calcar
with a novel conical flare and a mul-
tiplanar implant body for enhanced
rotational stability and surface area for
fixation (Fig. 30.6).
The Primoris™ Neck Replace-
ment has a collared lip for abutment
on the resected femoral neck and
Fig. 30.5 CUT™ stem.
may reduce the risk of subsidence.
A B
Fig. 30.6 (A, B) TSI™ neck implant.
Cross-section is trapezoidal for rota-

tional stability and optimizes fit and
fill of the neck (Fig. 30.7).
The Silent™ Hip optimizes
soft-tissue preservation; the original
design concept was by Dr Mathhius
Honl in Germany in 1997. It is a
neck only replacement that features
a taper style shape of titanium alloy
with a fully DuoFix™ cementless
coating. It features a 12/14 head
neck modular taper. The hip is avail-
able in five cross-sectional sizes at 2
mm increments. A variety of implant
lengths are available depending on
stem cross sectional size (Fig. 30.8).
Fig. 30.7 Primoris™ neck replacement.
Fig. 30.8 (A, B) The Silent™ hip by DePuy.

CONCLUSION
Helpful Tips
% We routinely use a modified antero-lateral approach for the hip joint
exposure.
% Radiographic control during the surgery is used by us as a routine and
recommended to all, especially during the initial learning curve.
% The neck is osteotomized high at the base of head with full preservation
of femoral neck.
% To prevent damage to greater trochanter-abductor complex and
Gluteus medius muscle, a ‘round the corner’ technique had been used
for broaching the femoral canal.
% Alignment can be checked at all steps by using an external alignment
rod on the insertion handle.
% The use of short anatomical stems in hip dysplasia’s can lead to an
excessive anteversion of the femoral component that can predispose to
dislocation. Therefore, careful planning must be done for these cases.
% A short stem can be a valuable option in cases with severe femoral
deformity or presence of previous implants, or even to ease the revision
of a fractured hydroxyapatite coated femoral stem.
% Use in patients with documented osteoporosis is still under evaluation.
We do not use these stems in such patients and do not recommended it.
CONTROVERSY
% Many of the medium and long-term results published to date corre-
spond to the author or authors of the implant; the results have to be
observed carefully. Level of evidence is not standardized.
% The learning curve of this stem is assumed to be equal to or longer than
conventional stems, but no series address it.
% The influence of conditions such as obesity and metabolic bone diseases
on the stem survival rate is yet to be defined.
% The failure pattern of these stems is yet to be known; it still has to be
proved that surgical revision is eased and that the revision can be done
with a primary conventional stem, although case reports are available,
but there is no serial study.
To summarize, there are potential benefits to these shorter stems, par-
ticularly for enthusiasts of the anterior approach who want to operate on
younger patients, the majority of these devices do not have long-term

results, and there is a need for careful collection and evaluation of data
and clinical trials. In the rush to use short stem devices as an option for
younger patients, care should be taken when considering other unproven
issues. Not all short stems generate the same radiographic findings and or
clinical results.
REFERENCES
1. Stulberg SD, Keggi J and Keppler L, et al. A classification system for short stemunce-
mentedtotal hip arthroplasty. Poster Presentation at the International Society for
Technology in Arthroplasty, Sydney, Australia, October, 2012, pp. 4–6.
2. Nunn D, Freeman MARR, Tanner KE, Bonfield W. Torsional stability of the femoral
component of hip arthroplasty. Response to an anteriorly applied load. J Bone Joint Surg
Br 1989;71-B:452–25.
3. Pipino F, Molfetta L. femoral neck preservation in total hip replacement. Ital J Orthop
Traumatol 1993;19(1):5–12.
4. Whiteside LA, MaCarthy DS, White SE. rotational stability of noncemented total hip
femoral component. Am J Orthop (Bella mead NJ) 1996;25(4);276–80.
5. Whiteside LA, White SE, McCarthy DS. Effect of neck resection on torsional stability
of cementless total hip replacement. Am J Orthop (Belle Mead NJ) 1995;24(10):766–70.
6. Morrey BF, Adams RA, Kessler M. A conservative femoral replacement for total hipar-
throplasty. A prospective study. J Bone Joint Surg Br 2000;82(7):952–58.
Chapter 31
Hi-Flex Knee Design

H.P. Bhalodiya, Somesh P. Singh
Modern total knee replacement (TKR) generally provides satisfactory pain

relief and improved knee function,1 but patients rarely regain full flexion.2
Most TKR designs enable the patient to achieve flexion between 110° and
125°, which is significantly less than the 140° to 150° that can be achieved
with a normal knee.3 Activities that require deep flexion, such as squatting,
kneeling and praying, are therefore often impossible for patients after TKR.4
Range of motion (ROM) is the most important outcome that defines
the functional ability after total knee arthroplasty (TKA). A minimum
range of knee flexion of 90° is essential to daily activities with about 67°
required in swing phase, 83° in climbing stairs, 90° in descending stairs and
93° in rising from a chair.5
Over the years, surgeons and knee designers have made certain changes
in the knee designs to improve the flexion of knee after TKR surgery. The
basic principle is to reduce the back side radius of the femoral component,
which in combination with partial posterior coupling helps in achieving
more than 120° of flexion.6 Also due to demographic changes, increasingly
young patients require TKA, and this means that the expectations of near
normal ROM of knee (e.g., flexion over 120°) are also increasing. It is no
longer enough to ensure freedom from pain and to allow everyday activi-
ties only gives successful results as per patient’s expectations; however, most
patients expect a free ROM which is often promised by the advertisement
of high-flex TKAs.7
Preoperative range of knee motion, etiology, BMI, patient age and knee
society score are among the most important factors that affect the final out-
come.8,9 Surgical technique, implant design and postoperative rehabilitation
are also said to affect the final knee ROM.9,10
Implant design is an important variable in achieving high flexion along
with patients’ factors and surgical technique. Therefore, implant manu-
facturers have attempted to design TKAs that better accommodate knee
mechanics in high flexion up to 155°.11,12 This allows deep knee flexion
activities such as squatting and sitting cross-legged, which requires knee
ROM up to 110 to 130º.13
Hi-Flex Knee Design 351
PATIENT FACTORS
Age
Schurman et al.14 found that gain in ROM was better in younger patients
at 3 months post surgery. Franklin et al.15 reported older age groups to
have a poorer outcome when compared to younger ones. Farahini et
al.16 reported univariate analysis showing good correlation (r = –0.102,
p = 0.04) with postoperative flexion angle; however, multivariate analysis
showed no significant correlation. In contrast, Anouchi et al.17 reported no
correlation between age and postoperative knee ROM.
Gender
Harvey et al.18 reported in his study that sex had no correlation in affecting
the final knee ROM postoperatively in conventional TKA. Other studies
also showed no relation between sex and ROM.19,20
Body Mass Index

Obesity has an adverse effect on postoperative knee ROM due to soft tissue
impingement between the femur and the tibia, which restricts the flex-
ion of the knee.15 Studies show that patients who were obese had higher
chances of a poor ROM.18,19,21,22
Type of Disease
Studies have reported that patients suffering from rheumatoid arthritis (RA)
had poor preoperative ROM compared to osteoarthritis (OA). Harvey et
al.18 described the type of disease as the most important factor in predicting
ROM after TKR. Ritter and Stringer23 evaluated 145 consecutive TKAs
and found that the knee flexion range increased by 2° in RA patients,
a nonstatistically significant difference. In our study, there was significant
difference in preoperative ROM between the OA and RA groups with
RA group having lesser preoperative ROM. Postoperatively, the RA group
showed a significantly greater increase in ROM in agreement with most
published studies.18,19 The final flexion angle was greater in OA group and
this was significant at the end of 1 year when compared with RA group.
Thus, although patients with RA had better gain in ROM, the final ROM
was better in OA group. Preoperative ROM increased preoperative ROM
has proved by several studies that there is a greater postoperative flexion arc
achieved by the patient.
Preoperative Range of Motion

Kurosaka et al.24 and Harvey et al.18 reported that preoperative ROM of
the knee joint was the most important factor with patients with good pre-
operative ROM showing better final outcome.
Preoperative Flexion Deformity and Postoperative Range of

Motion
A positive correlation between preoperative and postoperative ROM is
well established.19,24 However, preoperative ROM had negative correla-
tion with gain in ROM indicating patients with more preoperative ROM
did not gain much range (preoperative ROM a postoperative ROM/gain
in ROM). Kawamura and Bourne10 concluded that preoperative flexion
deformity did not correlate with final ROM.
SURGICAL TECHNIQUE
Surgical techniques are the most important determinant in achieving
high flexion ROM after TKR as this factor is in control of surgeon’s
hand. Multiple variables during the surgery have been studied and report-
ed which affect the final ROM after TKR surgery. In a 3D computer
model with cruciate retaining (CR) knee, Walker and Garg25 reported
that change in tibial slope by increase or decrease of 10° can result in 30%
increase to 25% decrease in flexion. They also reported importance of
component placement, that is, change in placement of tibial component
by 5 mm posterior or anterior can result in 5% increase to 10% decrease,
respectively, in final flexion. In another similar computer model study
using posterior stabilized (PS) knee,26 increase in tibial slope did not show
similar beneficial effects. Achieving good posterior cruciate ligament
(PCL) balance in CR knee has shown to have a positive effect in good
ROM.27 When comparing conforming vs. flat tibial insert, no difference
was found in between the two.28,29 Regarding restoring the joint line and
patellar thickness issue, an increase of patellar thickness by more than 20%
resulted in poor ROM. Similarly elevation of joint line was directly cor-
related with poor flexion.30 Lee et al.31 introduced the concept of gravity
flexion and reported that final flexion after TKR was within 10° of on
table gravity flexion. Certain key surgical technique points are discussed
in detail in the following section.
Inadequate Flexion and Extension Space Balancing

It is indeed very important to get a matched rectangular flexion extension
gap while doing TKR surgery. A mismatch in this can lead to poor outcome
in otherwise satisfactorily mechanically aligned TKR surgery. A flexion space
too tight can lead to excessive tension in the surrounding soft tissue result-
ing in clinically as persistent flexion deformity or extension lag or reduced
postoperative flexion and stiffness. A flexion space too loose can result in
postoperative instability and may result in dislocation especially in a PS TKR
surgery. Nowadays, most knee designs have an equal thickness of metal in
flexion and extension region and poly insert in tibial base plate equally affects
both flexion and extension space. It is imperative to have a matched rectan-
gular flexion extension gap while doing a TKR surgery, if the surgeon faces
a tight flexion gap limiting desired flexion of knee, he may address this issue
by either downsizing the femur or by some increase in posterior tibial slope
or by adequate posterior release.
Femoral Component Rotation

Optimal femoral component rotation is another important factor that con-
tributes to good postoperative knee flexion. If the femoral component is
placed in internal rotation, it leads to patellar mal tracking, and tightness of
lateral retinacular structures limiting knee flexion.
If the femoral component is placed in too much external rotation, it leads
to stretching of medial collateral ligaments and medial retinacular structures
limiting knee flexion. Also one must note that in a severely arthritic knee, the
landmarks for femoral component rotation reference may be affected and dif-
ficult to judge. Posterior condylar axis is the most commonly used landmark
and in certain situations, that is, RA, the lateral posterior condyle itself may
be deformed with valgus deformity; other two references include Whiteside
line and Epicondylar axis. It is better to cross-check the optimal rotation of
femoral component using all the three landmarks rather than relying on a
single reference landmark.
Posterior Condylar Offset and Posterior Clearance

Restoring the posterior condylar offset was thought to be another important
factor with respect to maximizing postoperative flexion. Bellemans et al.32
reported that the magnitude of posterior condylar offset correlated with the
final ROM. However, Hanratty et al.33 reported no statistical correlation
between the two. Recent literature suggests that change of posterior condylar
offset within 4 mm does not affect clinical results or postoperative ROM

when there is an acceptable balance of flexion extension gap in TKR surgery.
Another important surgical error while performing TKA is inability to
clear the posterior surface of femoral and tibial condyle, which may result
in poor postoperative knee flexion. If not cleared, it may obstruct knee flex-
ion by causing impingement against the tibial liner posteriorly. We follow a
simple technique by elevating the femur and removing all osteophytes using a
curved osteotome, any remnant part of meniscus and PCLs. A finger is passed
to feel any loose bodies or residual bone, which could block the flexion.
Anterior Clearance
Clarence of anterior compartment is as important as the posterior compart-
ment in achieving optimal flexion of knee after TKR surgery. Overstuffing of
anterior compartment due to suboptimal anterior cut or increased thickness
of prosthetic component or improper chamfer cut of placing the femoral
component in flexion can increase the tension on anterior structures of the
knee. This will lead to increased tension on quadriceps tendon, with reti-
nacular structures resisting deep flexion of the knee.
Similarly, while replacing the patellar component, if the prosthetic–patel-
lar bone composite thickness is increased as compared to preoperative state,
this also may contribute to increased soft tissue tension on retinacular struc-
tures limiting deep flexion. On the tibial side, most designs nowadays provide
relief for ligamentum patellae in tibial insert or tibial component; it is bet-
ter to place the tibial base plate slightly posteriorly than anteriorly to avoid
impingement of ligamentum patellae specially in deep flexion. Finally, good
patellar tracking and femoral rollback must be achieved so as to assure proper
soft tissue tension in anterior compartment around prosthetic component if
the tissue appears to be tight, especially on lateral side, a lateral retinacular
release must be done to assure good patellar tracking.
Tibial Slope
Most surgeons generally accept that increasing posterior slope will lead to
increased flexion gap and improved flexion of the knee in TKA. This con-
cept is, however, not substantiated in the literature. Also there is difference
in knee flexion behavior for same amount of increased posterior slope in
a CR knee vs. a PS knee. In a recent study, Xiajun Shi et al.34 showed that
every 1° of increase in tibial slope resulted in increased flexion by 1.8° in
PS TKR surgery. Ken Okazakiemail et al.35 reported in another study that
with change in the tibial slope by 5°, the flexion gap changed approximately
2 mm with CR-TKA and 1 mm with PS-TKA. With regard to tibial slope,
however, it is important to note that altering the slope also influences ante-
rior stability of the knee.36 Andrej Maria Nowakowski et al.37 concluded in
a recent study, ‘Increasing the tibial slope beyond the preoperative planning
in order to widen a tight flexion gap intra-operatively is not recommended
as doing so will increase the extension gap simultaneously and will make the
medial and lateral flexion gaps unequal.’This may result in anterior instability
or mid flexion laxity. We therefore believe that the increase of the tibial slope
should not exceed beyond preoperative planning to increase the flexion gap;
instead equilibration should be achieved via a ligament balancing procedure,
without the use of additional bony resections.
HIGHFLEX KNEE DESIGN CHANGES FIG. 31.1

Most traditional total knee prostheses were designed to accommodate
flexion up to 120° safely. While greater ROM was possible in certain cases
even with traditional design, the biomechanics of the prosthesis were not
optimized to have higher degree of flexion. Fear of accelerated wear due
to high point stress contact and edge loading between posterior femoral
condyle and prevented arthroplasty surgeons to advice deep flexion activi-
ties to even those patients who had good ROM.
With the advent of new millennium, improvement in prosthetic mate-
rial with high wear characteristics and geometric design changes in the
knee prosthesis have given confidence to the surgeons to safely allow deep
flexion activities without fear of early wear and failure of the TKA surgery.
Also, with changing demographics, more and more younger patients who
are still very active in their life are undergoing knee replacement surgery
Their expectation is not only pain relief but to have good deep flexion so
that they can live their normal lifestyle even after TKR surgery.
This has led to the implant manufacturers to come up with pros-
thetic design changes which allow deep flexion up to 155° without fear of
increased wear rate and affecting overall survival and longevity of the knee
replacement surgery. Several design factors in form of change in the geom-
etry of prosthetic component have been accommodated so that patients
can achieve high flexion safely. The femoral component has been designed
with extended posterior condyle radii or extended ‘J’ curve. This increases
the contact area of the femoral component to the tibial insert in deep knee
flexion avoiding edge loading of the femoral component and high stress
Fig. 31.1 High-flex design changes.
area on the tibial insert. This also increases the posterior condylar offset,
which helps in providing deep flexion.
Changes on the tibial side include cut out on anterior midline aspect
of tibial insert providing relief to ligamentum patella in deep flexion and
avoiding impingement of inferior pole of patella and ligamentum patellae.
The box in the femoral component has been deepened in some designs.
The groove of patella–femoral articulation has been extended more dis-
tally and posteriorly than the traditional PS component. This allows bet-
ter patella–femoral articulation with optimized patella–femoral tracking,
preventing lateral overload and improved patella–femoral joint mechanics.
PRESENT CLINICAL STATUS TABLE 31.1

Literature seems to be divided in establishing superiority of high-flex knee
designs compared to standard PS design in terms of achieving higher degree of
postoperative flexion. While certain authors38–41 found high-flex design gives
better flexion as compared to nonhigh-flex implants, others42–44 could not
find clinically significant difference between high-flex and traditional implants.
High-flexion TKR has been introduced with the goal of restoring an
increasingly large ROM that may be needed for specific functional activities.
Whereas the typical arc of motion after a TKR rarely exceeds 115°, some
cultural and religious activities may require knee flexion of up to 165°.53,54
Design changes aimed at increasing the ROM included smaller poste-
rior femoral condyle radii, altered polyethylene geometry to avoid patellar
impingement and to facilitate better roll-back, as well as alterations of the tib-
ial post to delay its contact with the femoral cam at higher degrees of flexion.
However, these innovations also introduced new specific problems, such
as a potential for accelerated wear when the thinner posterior polyethylene
or the patella are exposed to high contact stresses inherent with deep flex-
ion. Decreased articular conformity of the design and a relative collateral
ligament laxity, inherent with increased amounts of flexion, could produce
flexion instability. Changes in the femoral design often necessitate increased
bone resection from the posterior condyles or the trochlea, which becomes
problematic in smaller femora. In some studies, patients who underwent
a high-flex TKR and achieved a higher degree of flexion, especially with
weight bearing in that position, had higher rates of complications with
aseptic loosening and the need for revision.55 In a review of literature by
Murphy and colleagues, five of the nine studies showed an increased ROM
with high-flexion designs.56 However, only two of the studies looked at
culturally specific activities, and only one found an increase in the ability to
squat. Almost half of those patients could not get up without assistance, and
all of the patients reported that they did not squat in their daily activities.
There were no differences in the reported functional outcome scores
at the longest follow-up of 35 months. In a different meta-analysis by Luo,
high-flex total knees offered no improvements in the final ROM or knee
society scores.57 Several recent randomized controlled studies similarly
Table 31.1 Overview about the recent literature especially with regard to function/
flexion ability after total knee arthroplasty (TKA)
Author Study Journal Number of TKA Average Average
design patients follow-up flexion
angle
Huang HT, Matched J Arthroplasty 25 patients High Flex vs. 2.4 years 138° vs.
Su JY. pair 2005 Traditional PS 126°
et al.39 control
Vince KG, Follow-up J Bone Joint 58 patients Traditional 10-12 91.2°
Insall JN Surg Br 1989 TKA CR years
et al.45
Aglietti P, Follow-up J Arthroplasty 60 patients Traditional 10 years 106°
Buzzi R 1999 LPS vs LPS
et al.46 Flex
Gill GS, Follow-up Am J Knee 223 patients Traditional 16.8 years n.a.
Joshi AB47 Surg 2001 years TKA
Kim YH, RCT J Bone Joint 50 patients Traditional 2.1 years 135.8° vs
Sohn KS, Surg Am (bilateral) LPS vs LPS 138.6°
Kim JS.42 2005 Flex
Bhan S, Prospective J Bone Joint 32 patients Traditional 6 years 106.9°
Malhotra R Surg Am CR
et al.48 2005
Seon JK, RCT Orthopedics 100 patients Traditional 2 years 130.7° vs.
Song EK 2005 CR vs. 128.5°
et al.44 High Flex
Laskin Cohort Orthopedics 80 patients Traditional PS 2 years 118° vs.
RS38 study 2007 vs. High Flex 133°
Nutton RW, RCT J Bone Joint 56 patients Traditional PS 1 year 121° vs.
van der Surg Br 2008 vs. High 127°
Linden ML Flex PS
et al.49
Chaudhary RCT J J Bone 100 Traditional 2 years 105.9° vs.
R, Beaupré Joint Surg patients CR vs. 105.8°
LA et al.50 Am 2008 Traditional PS
Seon JK, Prospective J Bone Joint 100 patients Traditional 2 years 134.3° vs.
Park SJ Surg Am CR vs. High 135.3°
et al.51 2009 Flex CR
Kim YH, RCT J Bone Joint 250 patients High Flex 2.3 years 133° vs.
Choi Y Surg Am (bilateral) CR vs. High 135°
et al.52 2009 Flex PS
failed to show any clinical benefit to the high-flexion designs.58,59 Even

if increased ROM is achieved, its potential to affect functional outcomes
remains unclear. Miner and colleagues compared a questionnaire-based
assessment, the WOMAC score, and the objective measurement of the
knee ROM in their accuracy of predicting the postoperative satisfaction
and quality of life improvement. They noted a significant worsening in the

WOMAC pain and function scores in patients who achieved less than 95°
of flexion. Only the WOMAC scores were predictive of the patient satis-
faction and the perceived improvement in the quality of life.60 Although it
may be inferred that a restricted motion may have a negative influence on
the outcomes, there is little evidence to support that an exceedingly high
ROM provides a tangible benefit in terms of functional outcome scores.
Devers examined whether increasingly high flexion improved patient
satisfaction, perception, and function after a conventional TKR. Although
increased knee flexion had a significant correlation with achievement of
expectations, restoration of a more ‘normal’ knee and functional improve-
ment, overall satisfaction after surgery did not increase.61 A possible expla-
nation is that given a high rate of pain and functional improvement after a
TKR in a typical patient, the marginal benefit derived from high flexion
was too small to measure, suggesting the difference is not clinically signifi-
cant. As a result of these findings, some of the recent advances in TKA have
focused on reproducing native knee kinematics to achieve a more normal
feel in the knee rather than purely examining flexion. Both the PS and
CR conventional total knees fail to recreate the physiologic rollback, as
the femur shows paradoxical anterior subluxation in flexion. Medial pivot
total knee design aims to prevent anterior subluxation by increasing the
congruency of the medial compartment, which creates a ball-in-a-socket
articulation and allows the lateral side to roll back further in a fashion simi-
lar to the native knee joint. Fluoroscopic studies have demonstrated that
the medial condyle position stays constant with flexion, while the lateral
side rolls back in these designs.62 Patellar tracking and quadriceps function
is also optimized by maintaining the quadriceps level arm.63
CONCLUSION
Driven by manufactures advertisement and media hype, arthroplasty
surgeons today face this difficult situation of practically all the patients
demanding high flexion postoperatively, especially in our part of sub-
continent. Using a high-flex joint does not guarantee its ability to achieve
flexion up to 155°. Surgeons have to understand that using high-flex design
allows safe flexion up to 155° with claimed safety of ‘not affecting acceler-
ated wear rate’ (Fig. 31.2). Achieving high flexion depends also on patient
factors and precise surgical technique.
High-flex design still has to prove its superiority in the long-term
A B
Fig. 31.2. (A) Range of motion with high flexion knee. (B) Cross-leg sitting.
follow-up (10–15 years), with the focus on the degree of polyethylene wear
and the possible consequence of aseptic loosening. High flexion TKA must
be done with appropriate patient selection and precise surgical techniques
to obtain successful outcomes.
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PART 5
How do I Plan My Trolley:

Special Instruments
Chapters
32. My Trolley for Total Hip Arthroplasty 367
33. My Trolley for Total Knee Arthroplasty 384
Chapter 32
My Trolley for Total Hip

Arthroplasty
Javahir A. Pachore, Vikram I. Shah, Ashish N. Seth
Preoperative planning, which includes good clinical examination, local

soft tissue envelope and operative scars around the hip, needs to be taken
into consideration. Medical comorbidities from anaesthesia point of view,
good quality radiograph anteroposterior (AP) and lateral, which includes
upper third of femur, need to be taken into account. The special X-rays
like judet views, CT scans may be required for acetabular fractures, dysplasia
and patients with excessive anteversion. This planning should be executed
at the time of first consultation and
should be repeated as an exercise
before surgery.
Surgical trolley and its prep-
aration are equally important to
execute the procedure efficiently.
Proper instrumentation, implant,
equipment and surgical team reduce
operating time, blood transfusion
rate, complications, and most impor-
tantly reduce stress level of surgeon
and his team, and induce rapid
recovery. Too much instrumentation
on the operating table confuses the
scrub nurse; hence, it is mandatory
to have proper protocol for primary, Fig. 32.1 Trolley with instrument set.
complex primary hip replacement
and revision surgeries. Laying out surgical instruments step-wise is an art
practised scrub nurses and their training is the surgeon’s responsibility. The
different surgical trays are labeled according to the type of replacement.
Once the trays are in the OR, it is convenient for the circulating nurse to
open whichever is needed. This also reduces the traffic in and out of the
OR which may disturb the OR environment (Fig. 32.1).
368 Part 5 | How do I Plan My Trolley: Special Instruments
PRIMARY HIP REPLACEMENT

This includes general instruments
with two types of Charnley's self-
retaining retractors. Obese patients
need Charnley's deeper retractor for
good exposure, otherwise chances
of fat necrosis are very high. The
cautery tip of two sizes should be
available as routine tip may not reach
acetabular floor to take out pulvinar
pad of fat (Fig. 32.2). Fig. 32.2 Long and short cautery tip.
If you are choosing a posterior
approach, the anterior swan retractor
should be of two sizes depending on
the size of patients. This anterior
retractor helps to keep neck away to
expose the acetabulum and allows
proper oriented acetabular reaming.
Due to improper retraction, there
is a possibility of acetabular retro-
version. Charnley's pin retractors
are the key to success of acetabular Fig. 32.3 General instrument set.
exposure. For sclerotic bone mainly in the roof of acetabulum, one should
use high speed burr to open the cancellous area. This allows the capture of
the acetabulum reamers (Fig. 32.3).
On the femoral side, the measurement scale should be available to measure
vertical and horizontal offset from fix point. The trick is to take a fixed point
at the intertrochanteric area and put the cautery tip reverse or drill the point
and measure the vertical offset from intertrochanteric area to center of the
head and horizontal offset from centre of head to piriformis fossa (Fig. 32.4).
Fig. 32.4 Measurement of vertical offset and horizontal offset.

My Trolley for Total Hip Arthroplasty 369
Anterior neck retractor for fem-

oral preparation has been devised
by Wagner, which allows excellent
exposure for reaming of the canal.
The abductor retractor which is
hook type of retractor helps in
assessing proper entry of trochan-
teric fossa and prevents damage to
abductor muscles. The opening of
the femoral canal should have two Fig. 32.5 Box Chisel curved and straight.
different box chisel sizes. Most of
our Indian femur proximal configuration is small in AP dimension. Use
angled box chisel which allows proper entry and avoids trochanteric abut-
ment or hindrance (Fig. 32.5).
The canal which is narrow is dif-
ficult to open with routine reamers;
hence, you need long thick drills to
open the canal which can follow a
small intramedullary reamer on guide
wire. This is a personal modification
of flexible reamers from 32–12 mm
with length of 200 mm and short
guide wire. As in total hip surgery,
one does not require to drill below Fig. 32.6 Short intramedullary reamers
the isthmus; hence, these reamers are with guide wire.
extremely handy to maneuver (Fig. 32.6).
Sclerotic trochanteric area needs
high speed burr otherwise femoral
prosthesis goes into varus. A 60°
angle curette allows us to remove
bone from trochanteric and pirifor-
mis area. This facilitates the proper
entry of femoral stem (Fig. 32.7).
The acetabular reamers with
their attachments are in one tray
(Fig. 32.8). The reamer size usually
Fig. 32.7 High speed burr and 60 degree
starts from 37 mm and goes up to 64 angled curette.
mm. If one is planning for revision,
one should ask for higher size reamers and their trials. These reamers need
to be changed frequently as they lose their sharpness. The angled reamer

for acetabulum is helpful in mini approach which avoids the vertical place-
ment of the cup.
Femoral tray consists of intramedullary reamers and broaches (Fig. 32.9).
Every company has different philosophy as far as femoral stems are con-
cerned. Now most companies have the philosophy to preserve bone rather
than excessive reaming. Bone compaction is more favored than bone remov-
al. Nowadays, we call for an osteoprofiler, rather than a rasp.
Fig. 32.8 Acetabular reaming set. Fig. 32.9 Femoral tray.
SPECIAL SITUATIONS
Implant Extraction Assembly

Implants to be removed during total hip replacement may be cancellous
screws of various diameters, dynamic hip screws, proximal femoral nails,
Smith Peterson nail, Jewett nail, Wain–Wright plate, etc. (Fig. 32.10).
Most of them have an extraction assembly of their own, which needs
to be procured beforehand by finding out the manufacturer (Fig. 32.11).
During the implant removal, there is a possibility of breakage of the
screw head, leaving behind the shaft of screw. This broken screw removal
is possible only by use of a hollow-mill. The trick to use a hollow-mill is
to use reverse drill (Fig. 32.12).
Various sizes of screw-drivers should be available in separate packs which
include 3.5, 4.5 and 5.5 mm (Fig 32.13). The new varieties of proximal nail
have large diameter of screws with head diameter of 5.5 mm with hexagonal
head. On radiographs, it is difficult to assess the diameter of screw and head.
The sterile allen key set is a useful tool but it does not generate enough
torque. Rarely one may need slotted screw driver and Phillips head screw
Fig. 32.10 Various types of implants –

cannulated cancellous screws, dynamic
hip screw, Jewett nail, Enders nail, Smith
Peterson pin and plate, Wain–Wright
plate, proximal femoral nail.
Fig. 32.11 Extraction assemblies for universal proximal femoral nail removal set with
hollow meal, diamond wheel cutter for cutting implants, instrument for removal
dynamic hip screw, SP pin extraction device.
Fig. 32.12 Removal of broken screws with hollow meal.

driver. All these screw-drivers and

extraction devices are to be packed
separately and sterilized. Hence, it
comes in handy to open what is
required rather than hunting for the
tray. The implant removal should not
be taken lightly as at times it can be
difficult and time consuming. If one
does not have the instruments, one
may have to abandon surgical proce- Fig. 32.13 Various sizes screw driver
dure and feel sorry for not planning packed separately sterilized with plasma.
preoperatively.
Extractions for Austin Moore Prosthesis/Bipolar

Most Austin Moore (AM) prosthesis
have a fibrous in-growth around the
fenestrations, hence extraction is dif-
ficult. There are few key instruments,
that is, large bone hook, extraction
device which can be put on AM lat-
eral hole and flexible osteotomes to
remove fibrous tissue (Fig. 32.14).
If flexible osteotomes are not
available, one can use reciprocating Fig. 32.14 Austin Moore prosthesis
saw. Curved punch or cold chisel extractor.
is a valuable instrument to punch
the AM prosthesis which has a collar (Fig. 32.15). After the removal of
the implant, reverse hook curette is valuable instrument to remove the
Fig. 32.15 Austin Moore prosthesis removal set.

fibrous tissue. After the removal of the fibrous tissue, high speed wheel
burr is essential to open the cancellous bone. Most implants of this
nature have cortical sclerotic bone, which needs to be perforated. The
distal pedestal bone should be opened under the image guidance with a
thicker drill to avoid perforation.
Cases Requiring Trochanteric Osteotomy

In few patients, surgical exposure can be difficult like ankylosed hip with
external rotation, severe protrusio, acetabular fractures with stiff hip, dys-
plastic hips, old Perthes with secondary arthritis with coxa vara. As a hip
surgeon, one must master the trochanteric osteotomy and its reattachment
(Fig. 32.16). And this procedure can bail one out from difficult situations.
Fig. 32.16 Trochanteric osteotomy with required instruments.

One can do this osteotomy with broad thin osteotome, saw or gigli saw.
Reattachment is done by Charnley's wire technique, which includes verti-
cal and horizontal wires. When trochanter is small, you can add tension
band device with two K-wires. The importance of trochanteric stabiliza-
tion is to give stability in AP and supero-inferior directions. Several modi-
fications have been described. The AO wire loops of 132 and 20 gauges
are adequate. The AO tensioner device is most ideal for tensioning these
wires. Today we do not use Charnley's wire tightner as this instrument is
cumbersome. Instead of wires you can use cables with their appropriate
instrumentation, but these are expensive.
Cases Requiring Subtrochanteric Shortening

Patients with severe coxa vara, high neglected dislocations and old Perthes
with coxa breva may need subtrochanteric shortening. The ideal implant for
this type of situation is modular system like S-Rom, which stabilizes both
proximal and distal fragments. If the system is not available, one can keep a
titanium derotation plate with a unicortical screw. The screw should be rang-
ing from 10 mm to 14 mm as the implant comes in the way (Fig. 32.17).
Acetabular Dysplasia
The shallow acetabulum needs to be converted into hemisphere. Medial
osteophyte must be removed with a gouge to identify quadrilateral plate.
Cautiously drill medial wall and measure depth with depth gage. The ace-
tabular bulk graft must be fixed with two thick K-wires followed by hemi-
spherical reaming. Two cannulated cancellous screws either 4 mm or 6.5 mm
depending on size of graft should be used to stabilize the graft (Fig. 32.18).
Cases with Sickle Cell Diseases

Many of the patients of sickle cell have a blocked canal due to intra
medullary infarcts. Few patients with this disease have a double canal
(Fig. 32.19). Opening these canals is a laborious job and it is technically
demanding. This needs image intensifier, proper drills and cannulated
reamers. False tracts are known to occur due to sclerotic bone. The
compressibility of this bone is poor hence the chances of prosthesis
being undersized and placed in varus are high.
Revision of Cemented Acetabular Cup

Adequate exposure of acetabulum is key to success. This needs 360°
Fig. 32.17 High dislocation, S-Rom with

subtrochanteric shortening, dysplasia,
subtrochanteric shortening with derota-
tion plate.
exposure of acetabulum to see the interface between poly and cement.

Various sizes of curved gouge have to be used between cement and poly.
You can use two or three similar gouges to remove the cup. After removing
the cup, cement can be fragmented by thin sharp osteotomes; this must be
removed in piece meal. The anchor hole cement is to be removed with
small thin straight or curved long handle gouges (Fig. 32.20).
Fig. 32.18 Surgical steps of acetabular reconstruction with bulk graft in dysplastic hip.
Fig. 32.19. Sickle cell arthritis following avascular necrosis.

Femoral canal shows double canal.
Revision of Uncemented Acetabulum

Many companies have extraction device for the poly. Hence, we must know
what company implants the patient has. If it does not work, then use a 6.5
mm cancellous screw, inserted in the center of the poly, after pre drilling.
Fig. 32.20 Removal of cemented poly cup.
Fig. 32.21 Removal of uncemented poly with 6.5 mm can-

cellous screws.
This mechanism pushes the poly out as one tightens the screw (Fig. 32.21).
Removal of the uncemented well-fixed cup needs explants system.
This explant system has made surgeons’ life easy. It removes implant with-
out losing much of acetabular bone (Fig. 32.22).
Fig. 32.22 Explant system.

Fig. 32.23 Universal femoral component Fig. 32.24 Revision instruments for
extraction device. cemented stem.
Revision of Cemented Femoral Stem

After removal of the proximal cement, it is possible to hammer out mono
block stem with a universal extraction device. These extraction devices
have back punch facilities (Fig. 32.23).
Highly polished stems are easy to remove. Cement removal from the
canal requires great experience, patience and varieties of instrumentation.
The key instruments for cement removal are cement splitter, thin long
straight and curved osteotomes and good grasping forceps (Fig. 32.24).
While using these above instru-
ments, the hammer should be used
lightly and the hand should be closer
to hammer head rather than away to
reduce perforation chances. The light
source and proper suction device
for exposure of the cement bone
interface are crucial. The removal
of femoral cement requires patience
and the key instrument is femoral Fig. 32.25 Cement splitter (reverse chisel).
reverse chisel splitter (Fig. 32.25).
During the distal plug removal, if there is a radiolucency around it, it
can be pushed into the canal. If there is cement between distal plug and tip
of prosthesis, the removal is extremely difficult. The techniques which can
be used are as follows.
1. Under an image intesifier, drill the cement with various sizes of drill.
2. Make a distal window (Fig. 32.26).
3. Drill the cement, put the tap and use the reverse punch.
Ultrasonic cement removal requires experience. There is a possibility
Fig. 32.26 Window to remove distal

cement.
of damaging the endosteal bone if one is not familiar. With the help of a
probe, the distal cement is easy to remove after perforating it.
Removal of Well-fixed Uncemented Stem

These have very few indications like damage or broken taper, stem breakage
and poor track record of the stem. Various techniques have been described
in the literature. Follow couple of principles according to the type of stem.
Proximal coated stems are easy to take out. Fully coated stem like AML or
Solution are extremely difficult to remove. If there is a collar, the access in
the canal is difficult. For this type of implant your trolley should be ready
for transfemoral approach with its reattachment instrumentation like AO
loop wires or cables.
For proximal coated stem and
hydroxyapatite fully coated stem
without collar (Corail hip), thick K
wire on an electric or pneumatic drill
of proper length should be used all
around the prosthesis. The K-wire
should be drilled between the implant
and the bone junction. Due to flex-
ibility of the K-wire chances of per- Fig. 32.27 Removal of uncemented stem
foration are minimal (Fig. 32.27). The by using thick K-wire technique.
water irrigation helps to reduce the thermal reaction. It is easy to use K-wire
anterior, posterior and lateral but difficult on medial side. This technique helps to
break osteointegrated bonds. The next step is start using flexible osteotomes.
On the medial side, the osteotome should be of 10 mm size which will follow
medial curvature of implant (Fig. 32.28).
Once you feel there is good micro motion between the implant and the
Fig. 32.28 Removal of uncemented stem with flexible 10 mm osteotomes from the
medial side and 20 mm on medial and lateral side.
bone, then use the universal extractor with a reverse punch. Once in a while
you might have to hammer distally rather than using reverse punch. This
technique should not be used where there is sclerotic bone at tip of implant.
Instead of the flexible osteotome, there is possibility of using thin blade
reciprocating saw but it can remove only the proximal metaphyseal bone.
Extensive Coated Implants

These are more difficult to remove because most of them have a collar.
This collar does not allow the access between the bone and the implant. It
only allows the lateral access between the bone and implant. After getting
the proximal access, you can use the universal extractor and hope for the
best. If there is no micro motion with any positive signs of loosening, one
will have to consider transfemoral approach (Fig. 32.29). The extent of the
approach depends on the length of stem. Cemented stem with no debond-
ing sign between cement and bone in distal two-thirds may require trans-
femoral approach. In these cases, access of the cement bone junction is difficult.
If the stem is extending long enough below the isthmus, then do trans-
Fig. 32.29 Transfemoral approach.
femoral osteotomy at level of isthmus. With high speed burrs, cut the stem
at the level of the osteotomy. The proximal part of stem can be removed
with thin ostetomes or using a gigli saw anterior to the stem bone interface.
Keep multiple gigli saw ready as they break easily. The distal part of the stem
has to be removed with trephine; for this you must know dimensions of the
implant. This trolley needs multiple batteries and minimum two to three tre-
phines of the same size because trephine gets blunted in no time (Fig. 32.30).
The broken stem of fully coated implant is removed with trephine
Fig. 32.30 Trephine of various sizes with reverse serrations.
Fig. 32.31 Removal of stem using trephine.

(Fig. 32.31). Continuous irrigation of saline helps to prevent thermal damage.

The literature does suggest an alternative technique to remove the bro-
ken distal part of stem with a high-speed drill. First, drill in the center of
broken part of the stem, then tap it, followed by reverse punch.
The trolley needs a lot of thinking depending on the pathology being
dealt with. Fewer instruments make surgery quick and safe. Hence it is
mandatory to open only the instruments that are required, rather than
opening multiple sets and making the surgical experience complex for
the surgeon, nurse and colleagues. Individual sets, which are well labeled,
should be packed separately rather than being dumped in a single big tray.
Labeling the tray is of paramount importance with proper identification
and sterility mark. To make the procedure successful, the whole team is
important and every individual contributes towards the success or final
outcome of the surgery.
Chapter 33
My Trolley for Total Knee

Arthroplasty
Vikram I. Shah, Javahir A. Pachore, L. Bharath
Increasing demand for total knee arthroplasty (TKA) is a major concern for
an arthroplasty surgeon to give predicted and consistent results to patients.
Adequate training for the surgeon and other operating room personnel is
equally important to avoid complications. TKA demands adequate instru-
mentation, which backs up efficient implantation of the prosthesis of the same
unified system. Specified and limited instruments will make the procedure
systematic, less cumbersome and would avoid confusion among assistants,
thereby helping the surgeon in performing the task effectively.
Every surgeon in the course of his surgical experience gets tuned
to his desired instruments to make his procedure neat and simple.
But each patient has to be treated differently and the requirement of
intraoperative instrument varies. Hence, preoperative evaluation of the
patient, plan for surgery and arranging the required instruments in the
trolley are vital. The number of
operating room personnel is always
kept minimal in joint replacement
surgeries for various reasons. The
desired instrument sets are planned
and kept arranged in a movable
trolley before the procedure, which
will provide hassle-free environ-
ment (Fig. 33.1). The foot frame
will hold the knee in stable posi-
tion, thereby reducing the require-
ment of one assistant (Fig. 33.2).
Basic instruments required are
general surgical instruments, pros-
thesis design specific instruments
and power cutting tools, which are
arranged in three different trolleys. Fig. 33.1 Movable trolley.
My Trolley for Total Knee Arthroplasty 385
Fig. 33.2 Foot frame.
Fig. 33.3 General surgical instruments.

The general instruments includes mainly modified Hohmann and

Langenbeck retractors, laminar spreader, BP handle sets, forceps, towel clips
for draping, nibblers and osteotomes (also refer to Ch. 17 on Exposures and
Retractors) (Fig. 33.3). Keep the general surgical instruments as minimal
as possible since most TKA involves design-specific instrumentation. These
are placed in the first trolley.
The second trolley will lay out design-specific instrumentation like jigs for
femur, tibia and patella; pins; caliper; tibial keel preparation kits; patellar buttons
and trial implants arranged according to various sizes (Fig. 33.4).
The third trolley will handle a tray for oscillating power cutting saw,
drills, cement remover (Mc Donnell) and instruments for cement mixing
procedure (Fig. 33.5). Various sizes of saw blades help in making precise
bony cuts (Fig. 33.6). Ensure there is adequate space in the third trolley for
placing once used instruments from other two trolleys. This will help the
assistant for easy visualization of instruments required for the further steps
in first and second trolleys.
Most common situation encountered is when a specific instrument
is dropped on the floor. The panic can be avoided by having a spare of
every instrument either ETO or plasma sterilized, kept separately to
avoid opening of other major sets, which can hinder the next scheduled
case (Fig. 33.7). But this sophistication will only be available in high
volume centers.
Fig. 33.4 Design-specific instrumentation. Fig. 33.5 Third trolley.
Fig. 33.6. Different saw blades. Fig. 33.7. Sterilized standby instruments.
We emphasize surgeons to use

single system design-specific instru-
mentation regularly so that they
and their assistants are familiar with
instruments and implant, which
make them vigilant throughout the
procedure.
Pulsed lavage with 3 L single vol-
ume pack of normal saline is used as
a routine protocol for better cement Fig. 33.8 Pulsed lavage.
fixation (Fig. 33.8). Single volume
pack can prevent contamination in
the due course of repeated changing
of small volume pack to complete
the wash. As a part of general trolley,
the cocktail kit comprising various
drugs is presterilized in a single pack
(Fig. 33.9). This can avoid contami-
nation when individual components
are taken separately by the assistant.
Managing knees with bony Fig. 33.9 Cocktail kit.
defects require adequate pre op plan-
ning. Various methods of augmentation depend upon the size of the defect,
the amount of uncovered tibial tray and the quality of bone. Small defects
can be managed with cement and screws. Larger defects require a step-
cut or oblique osteotomy for coaptation of bone graft to host defective
bone with screws (Fig. 33.10). Different size and shape metal wedges can
Fig. 33.10 Large posteromedial defect.

(A) Anteroposterior (AP) view. (B) Intra-
A operative. (C) Postoperative. C
A B
Fig. 33.11 (A) Large posteromedial defect – anteroposterior (AP) view. (B) Large defect
managed with metal wedge.
supplement bone grafts in case of sclerotic bone bed (Fig. 33.11). Short
stem extension of the tibia or femoral components is used for mechanical
off-loading of the augments. Special instruments like reciprocating saw for
step-cut or oblique osteotomy, K-wires and 3.5/4.5 mm cortical or cancel-
lous screw set are kept on a standby
which are not a part of primary knee
trolley (Fig. 33.12). Elderly patients
have poor bone quality and in the
circumstances of iatrogenic avulsion
of medial epicondyle, one or two
3.5/4.5 mm cancellous screws with
washer may be required. The utmost
situation, a refractory medial tight- Fig. 33.12 Instruments for managing tib-
ness will necessitate medial epicon- ial defects.
dyle osteotomy. Fine osteotomes and screws are essential for osteotomy and
reattachment of the epicondyle.
Ligament insufficiency is commonly encountered in severe varus,
valgus, recurvatum deformities, and in stiff knee and revision situations.
Supplementation of various degree of constrained joint becomes essential
to balance the knee. The availability of constrained design-specific implants
and instrumentations should be a part of your surgical planning (Fig. 33.13).
Complex cases with previous surgeries like high tibial osteotomy, fractures
of distal femur and proximal tibia have staples, screws, plates and intramedul-
lary nail (Fig. 33.14). These hardware may be encountered during implanta-
tion of prosthesis. Preoperative planning for removal of hardware and nec-
A B
Fig. 33.13 (A) Varus knee with large defects. (B) Intraoperative ligament insufficiency –
semiconstrained design.
A B C
Fig. 33.14 (A) Intramedullary tibial nail. (B) Proximal tibia plating. (C) Distal femur plating.
A B C
Fig. 33.15 (A) Complete nail removal and total knee arthroplasty (TKA). (B) Only proxi-
mal screw removed. (C) Only distal screws removed.
essary instruments should be made available (Fig. 33.15a,b). Intraoperative

attempts of failure to removal entire hardware will necessitate removal of
only those hardware that are obstacle for fixing the prosthesis (Fig. 33.15c).
Dynamic condylar screws/angle blade plates used for previous distal femoral
fracture are really challenging to remove. Failed removal of screws will hinder
preparation of intercondylar box cut, hence cruciate retaining design can be
preferred (Fig. 33.16). But difficulty in negotiating the distal femoral jig is a
threat. This requires high level of expertise and may need navigation tool to
Fig. 33.16 (A) Dynamic condylar screw

(DCS) in situ anteroposterior (AP) view.
(B) DCS in situ lateral view. (C) Cruciate
retaining prosthesis with DCS in situ. C
produce better outcome in these patients. In special situations, high speed

metal cutting wheels and burr are made available. Various sizes of hollow mill
for removing of broken screws are always kept in reserve (Fig. 33.17).
Fig. 33.17 Metal cutting wheel, burr and hollow mill.
Stress fractures at proximity to knee joint, commonly encountered

in tibia, are managed effectively by long intramedullary stem exten-
sions (Fig. 33.18a,b). At scenarios, derotation plating or open reduction
of severe deformities with fibula osteotomy may be required before the
knee replacement procedure. Trauma instrumentation sets for osteotomy
is mandatory as a part of preoperative planning. Malunited and nonunited
stress fractures have abnormal remodeled bone formation (Fig. 33.19). In
such situations, intramedullary stem extensions will demand image (C-arm)
guidance to eliminate the risk of perforation (Fig. 33.20a, b).
A B
Fig. 33.18 (A) Varus knee with stress fracture. (B) Stress fracture – long tibial stem.
Fig. 33.19 Nonunion stress fracture with varus deformity.
A B
Fig. 33.20 (A) Intra op image at nonunion site. (B) Intra op image of offset stem.
Revision knee surgeries are procedures requiring meticulous involve-

ment of the surgeon and assistants. Various osteotomes, gauges and
punches are required for removal of preimplanted prosthesis with
minimal bone loss (Fig. 33.21). Surgeon-friendly revision design specific
instruments can reduce the stress during surgery (Fig. 33.22). Accessibility
to bone graft (allogenic) is an additional concern in case of aseptic loos-
ening revision knee. The prediction of bone loss due to osteolysis on
X-ray is usually two to three times less than actual intraoperative find-
ing. Nibblers, bone cutting instruments must be equipped for preparing
matchstick-sized grafts (Fig. 33.23).
Stiff, ankylosed and revision knees may require extended tibial tubercle
osteotomy to enhance surgical exposure and rarely for patella realignment
procedures (Fig. 33.24a,b). Special osteotomes, saw blades, cancellous screw,
K-wires and stainless steel wire can make the procedure effortless (Fig. 33.24c).
Fig. 33.21 Revision instruments. Fig. 33.22 Design-specific revision system.
Fig. 33.23 Matchstick-sized allogenic bone graft.
Rarely avulsion of ligamentum patella from the tibial tubercle may need
suture anchors to bail out the difficult situation.
To conclude, all patients should be treated individually and planned
preoperatively to execute the procedure efficiently. Planning should begin
from Day 1 of first consultation and re-evaluated the day before surgery
rather planning on table. It becomes the surgeon’s responsibility to arrange
for all required instruments for the planned surgery. Tuned environment
and planned surgery will reduce the time duration significantly thereby
most of intraoperative and postoperative complication can be avoided.
The conversant members of the team with good understanding can always
reduce the adrenalin gush of the surgeon and can contribute to a friendly
stress-free environment.
A B
C
Fig. 33.24 (A, B) Extended tibial tubercle osteotomy – antero-
posterior (AP) view (A), lateral view (B). (C) Instruments for
tibial tubercle osteotomy.
INDEX
Page numbers followed by “f ” indicate figures, “t” indicate tables and
“v” indicate video.
A Cement restrictors, 130
Acetabular cup, 87 Cementation techniques in TKA, 240
Acetabular monoblock cup, 89f bone preparation, 242
Acetabular templating, 80, 82f cement application and component
Acetabulum preparation, 106 insertion, 243
Addisonian crisis prevention, 9 cement preparation, 243
Anaesthetic measures, 22 operative technique, 241
Anchor holes, 122 Cemented hip, 118
Ankylosing spondylitis acetabulum exposure, 119
fused hips, 156 acetabulum reaming, 121
medical disease and management, 157 anchor holes, 122
Anterior clearance, 354 bone bed preparation, 123
Antibiotics added to bone cement, 241t surgical technique, 126
Antibiotics in cement, 48 templating, 119
Antibiotics, 7 Cemented stems, 91f
Antidepressants, 64 Cementing in TKA, 242v
Antiepileptics, 64 Cementless stems, 93f
Antifibrinolytics, 22 Clopidogrel, 10
Autologous blood predonation, 19 Cognitive changes, 8
Autotransfusion, 21 Column augments, 335
Condylar constrained knee, 198
B Convergence-projection hypotheses, 62
Bacterial decolonization, 40 Cup insertion, 124
Basic principles of alignment, 230 Cup orientation, 140
Bearing surface, 93 Custom-made prostheses, 298
Blade shape, 223 Cyclooxygenase inhibitors, 63
Blood transfusion reduction, 15
intraoperative strategies, 20 D
postoperative strategies, 24 Deep vein thrombosis, 5
preoperative strategy, 16 Determination of leg-length
Blood transfusion requirement, 32 discrepancy, 80
Bone cement composition, 240 Determination of magnification, 79
Bone grafts, 292 Dossick calcar to canal ratio, 144f
Broaching, 128 Drains, 29
in THA, 31
C postoperative, in TKA, 30
Calcar to canal ratio, 144f Draping, 45
Canal preparation, 129 DVT prevention, 5
Cardiovascular complications, 3 Dysplastic acetabulum, 82
Cement application and pressurization, 123
Cement guns, 132f E
Cement mixing, 130 Ensuring limb length equalization, 113
Cement pressurizers, 123f Epidural catheter removal, 10
396 Index
Erythropoietin, 16 G
Exposure in TKA, 211 Gloving, 46
basics, 211
surgical technique, 213 H
Extended intramedullary stems, 299 Haematoma size, 32
Haemostasis, 23
F Health optimization, 40
Factors affecting pain perception, 61 Hi-flex knee design changes, 355
Failed fractures with implant in situ, 153 Hi-flex knee design, 350
Femoral component positioning, 109
Femoral component preparation tools, 110f I
Femoral component rotation, 353 Identifying medial wall of acetabulum, 120
Femoral neck cut, 127 Identifying medial wall of pelvis, 120
Femoral neck resection, 145 Implant for THA, 87
Femoral preparation and component Implant selection in TKA, 190
placement, 146 Inadequate flexion and extension space
Femoral preparation, 126 balancing, 353
Femoral retractors, 126f Incision and exposure in THA, 103
Femoral stem, 88 Infection prevention, 37
Femoral templating, 83, 84f Instruments
Femur preparation, 109 acetabular dysplasia, 374
Fever after surgery, 4 case with sickle cell disease, 374
Fibrin spray, 23 extractions of Austin Moore
Fixed bearing TKA, 269 prosthesis, 372
cruciate retaining, 278 implant extraction assembly, 370
posterior stabilized, 270 primary hip replacement, 368
Folic acid, 18 removal of extensive coated
Fused hips in ankylosing spondylitis, 156 implants, 381
acetabular cup placement, 167 removal of well-fixed uncemented
altered anatomy, 157 stem, 379
approach, 161 revision of cemented acetabular cup, 374
clinical exam, 158 revision of cemented femoral stem, 378
closure, 169 revision of uncemented acetabulum, 376
computed tomography, 159 subtrochanteric shortening, 374
femoral reaming and stem trochanteric osteotomy, 373
placement, 165 Iron, 18
heterotrophic ossification
prevention, 170 L
neck cut, 164 Laminar flow, 46
positioning patient, 160 Lateral translation of tibial component, 289
posterior exposure, 165 Lateralized acetabulum, 82
preanaesthetic assessment, 160 Leg-length discrepancy, 80, 81f
preoperative radiological templating, 160
radiological investigation, 158 M
surgical procedure, 162 Metabolic syndrome, 11
Metal back tibial components, 197
Metal wedge augment, 297
Index 397
Metaphyseal sleeves, 298 Peritrochanteric fractures, 149

Mobile-bearing knee, 194f Personal protection system, 48
advantages, 196 POCD, 8
indications and contraindications, 196 Poly-ethylene cup, 125f
results, 196 Post high tibial osteotomy, 315
Mobile-bearing or fixed bearing, 194 Postarthroplasty antibiotics, 50
Mobile-bearing TKA, 280 Posterior clearance, 354
clinical outcome, 285 Posterior condylar offset, 354
surgical technique, 281 Posterior cruciate retaining knee, 191f
Multimodal management of pain, 65 Posterior cruciate retaining total knee
author’s preference, 69 replacement, 191
Posterior stabilizing knee, 193f
N Posterior stabilizing total knee
Need for ICU, 6 replacement, 193
Neuraxial anaesthesia, 64 Postoperative cognitive dysfunction, 8
Nociceptor-induced inflammation, 62 Post-surgery fever, 4
Normovolemic dilution, 21 Preoperative cocktail, 68t
Preoperative digital templating in
O THA, 114f
Obesity, 11 Preoperative skin preparation, 44
Operating room environment, 46 Preoperative treatment with
Operating room traffic, 48 epoetin alpha, 17f
Opioid analgesics, 63 Preserving limb length, 113
Prevention of heterotrophic
P ossification, 170
Pain management, 59 Principles of balancing, 233
Pain modulation, 62 balancing in valgus knee, 238
Pain pathway, 59, 60f balancing in varus knee, 235
Pain, 59 basic rule of balancing, 234
Patellar resurfacing in TKA, 249, 251v flexion gap balancing, 238
literature review, 249 technique, 235
surgical technique, 250 Prophylactic antibiotics, 41
Patient factors in choosing implant for Protrusio acetabulae, 82, 174
THA, 94 Proximal femoral geometry, 144
Patient positioning in THA, 101 Proximal femoral preparation, 127
Pelvic reference line, 81f Proximal seal, 132f
Periarticular injections, 65 Pulmonary complications, 3
Perioperative glycemic control, 8 Pulsatile lavage, 123
Peripheral nerve block, 65
Periprosthetic joint infection R
classification, 38 Radiographic landmarks identification, 79
definition, 38 Radiographic technique, 77
Periprosthetic joint infection Radiographic templating in THA, 79
prevention, 39 Radiological planning in primary
intraoperative, 43 TKA, 183
postoperative, 50 analog vs. digital templating, 187
preoperative, 40 CT vs. X-ray, 187
398 Index
Radiological planning in primary THA (author’s preference), 101

TKA (Continued) THA in peritrochanteric fractures, 149
extra-articular deformities, 186 approach, 150
how to plan, 184 THA in protrusio acetabulae, 174
patient specific instruments and component choice, 179
implants, 189 surgical technique, 176
role of MRI, 188 Tibial bone defects, 287
special radiographic views, 188 classification, 287
Radiological planning in THA, 75, 77v management options, 288
preoperative, 76 options to fill defect, 290
Range of motion results, 295
patient factors, 351 support for cement, bone graft or
surgical technique as determinant of augment, 299
ROM, 352 Tibial resection through the base
Reduction and closure in THA, 111 of defect, 288
Referred pain, 62 Tibial slope, 354
Restoring LLD, 113 Tips and pearls in THA, 101v
Retractor aspirator, 122f Tips for monoblock cups, 142
Retractors in TKA, 211 TKA in fixed flexion deformity, 302
Rim cutter, 122f postoperative management, 306
Rotating hinged knee prostheses, 199 preoperative evaluation, 303
Rotating platform TKA, 282v surgical steps, 303
TKA in post high tibial osteotomy, 315
S preoperative assessment, 315
Saw technique in TKA, 222 results, 321
Short stem designs, 341 technique, 316
biomedical advantages, 342 TKA in stiff knee, 217v, 308
bone conservation, 343 complications, 312
classification, 342 literature review, 313
metaphyseal stabilizing stems, 343 preoperative assessment, 308
neck stabilizing stems, 343 rehabilitation, 312
Single stage bilateral TKA, 9 surgery and implant selection, 311
Socket preparation, 141 Tourniquets, 24, 204
Soft tissue release, 299 calibration, checking and safety, 208
Staged TKA, 9 complications, 208
Stem geometry, 145 dimension and design, 206
Stiff knee, 308 inflation pressure, 207
Superficial infection, 11f inflation time and deflation interval, 207
Supplemental fixation, 142 method of application, 205
Surgeon factors in choosing implant special situations, 207
for THA, 94 Tourniquets and position in TKA, 204
Surgical considerations of mechanical Trabecular metal, 327
axis, 232 acetabular defects and use of TM shells
Surgical dressing, 49 and augments, 335
clinical applications, 332
T manufacturing process, 328
Tantalum, 328 rationale for TM reconstruction, 333
Templating, 79 salient features, 329
Index 399
Trabecular metal (Continued)

uses in knee arthroplasty, 337
Tranexamic acid, 22
U
Uncemented THA, 138
acetabular component, 138
design considerations, 139
femoral component, 143
indications and contraindications, 140
postoperative protocol, 147
surface and coatings, 139
technique, 140
Uncemented vs. cemented stems, 96f
Unicondylar knee arthroplasty, 257
history, 257
indication, 258
postoperative rehabilitation, 262
principle, 257
results, 263
surgical technique, 259
Urinary catheter removal, 7
V
Vancomycin indications, 43
Vitamin B12, 18
W
Wound closure, 49

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Basics in

HIP AND KNEE

Basics in Hip and Knee Arthroplasty, 1e, Shrinand V. Vaidya

Copyright © 2015, by Reed Elsevier India Pvt. Ltd.

Content Strategist: Dr. Renu Rawat

Total joint arthroplasty is truly one of the great surgical advances of

The demand for hip and knee replacement surgery is

All the Faculty Members and Residents of Department of Orthopaedics,

Everyone at Elsevier, who put up with me so patiently...

Shrinand V. Vaidya MS, FACS (USA)

Part 1 Planning of the Hip and Knee Arthroplasty

Part 2 Total Hip Arthroplasty: Techniques and Pearls

Part 3 Total Knee Arthroplasty: Techniques and Pearls

Part 4 Recent Advances in the Hip and Knee Arthroplasty

Part 5 How do I Plan My Trolley: Special Instruments

Planning of the Hip and

Total Joint Arthroplasty:

WHAT SHOULD I DO ABOUT CARDIOVASCULAR AND

at rest. It is approximately 3.5 mL of oxygen per kg per minute. Functional

HOW TO DEAL WITH FEVER AFTER SURGERY?

HOW TO PREVENT DEEP VEIN THROMBOSIS

instead of asymptomatic venography detected episodes. The new guide-

DOES MY PATIENT NEED ICU?

of needing critical care increasing gradually as 7.0%, 13.2%, 23.5%, 38.1%,

WHICH ANTIBIOTICS, WHEN AND FOR HOW LONG?

WHEN SHOULD I TAKE OUT THE URINARY CATHETER?

HOW TO MANAGE POSTOP COGNITIVE CHANGES?

HOW SHOULD I ACHIEVE GLYCEMIC CONTROL

HOW TO PREVENT ADDISONIAN CRISIS IN PATIENTS

DOES THE PERIOPERATIVE PROTOCOL DIFFER FOR

WHEN TO DISCONTINUE AND RESUME CLOPIDOGREL

WHEN SHOULD I REMOVE THE EPIDURAL CATHETER

be administered 2 h after the catheter removal or 24 h after the catheter

HOW DO OBESITY AND METABOLIC SYNDROME

Fig. 1.1 Clinical photograph of delayed wound healing and

Many obese patients also suffer from comorbidities like obstructive

TAKE HOME MESSAGE

erative screening, planning and timely intervention, there is no excuse for

joint arthroplasty in the elderly: a meta-analysis. J Arthroplasty 2014;29(2):261–7.e1. doi:

Blood Transfusion Reduction in

used to reduce blood loss and transfusion requirement. Lastly, intraopera-

>10 to ) 13 g/dL )10 or >13 g/dL

If the preoperative Not a candidate for

If the preoperative period

Although EPO is costly, the effectiveness of this medication in elevating

Iron, Vitamin B₁₂ and Folic Acid

stored as ferritin. The remainder of total body iron is circulating in the

Autologous Blood Predonation

esis to occur between donations; again appropriate iron supplementation

Individualized Transfusion Threshold

of patients requiring allogeneic transfusion associated with aprotinin and

recent meta-analysis on its use in TKA before wound closure concluded

a statistically significant decrease in transfusion requirement but also

operative blood loss after total knee arthroplasty]. Orthop 2011;40(2):178–82.

Role of Drains in Primary Total

POSTOPERATIVE DRAINS IN TOTAL KNEE

for prophylaxis vary in different centers. Some surgeons claim performing

USING DRAINS IN TOTAL HIP ARTHROPLASTY

Drains and SSIs

should be removed 24 h after the surgery, as they do not reduce the

Size of the Haematoma

Postoperative Requirement for Blood Transfusion

postoperative exercise can be restricted by pain and swelling.37

Length of Hospital Stay